Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson...

Finding Answers: Disparities Research for Change

A National Program of the Robert Wood Johnson Foundation at the University of Chicago

How Cultural Competency, Language Access, and Health Literacy Are Integrated Into Programs and Interventions Aimed At

Reducing Disparities

Marshall H. Chin, MD, MPH

Richard Parrillo Family Professor

Director, RWJF Reducing Health Care Disparities Through Payment and Delivery System Reform

University of Chicago



Disclosures / Funding AHRQ T32 HS00084, K12 HS023007, U18

HS023050 The Commonwealth Fund HRSA John A. Hartford Foundation Merck Foundation NIDDK K24 DK071933, R18 DK083946-01A1, P30

DK092949 Robert Wood Johnson Foundation National Quality Forum committees President, Society of General Internal Medicine CMS Innovation Center – technical assistance



A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care

Chin MH, et al. JGIM 2012; 27(8):992-1000

www.solvingdisparities.org



Roadmap for Reducing Racial and Ethnic Disparities in Care

1) Recognize disparities and commit2) Implement QI infrastructure and

process3) Make equity an integral part of

quality4) Design intervention(s)5) Implement, evaluate, and adjust

intervention(s)6) Sustain intervention(s) Chin MH et al. JGIM 2012; 27:992-

1000



Roadmap for Reducing Racial and Ethnic Disparities in Care

#1 Recognize disparities and commit to reducing them

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



Examine Your Performance Data Stratified by Race, Ethnicity,

Language, and SES

Individual and organizational readiness to change



Make Sure Your Disparities Training is State of the Art

SGIM Goals for Health Disparities Courses

Existence of disparities, etiologies, solutions

Mistrust, subconscious bias, stereotyping

Communication, trust building Commitment to reduce disparities

Smith WR et al. Ann Intern Med 2007; 147:654-665



Univ. of Chicago Course• Self-insight exercises• Field trips & Chicago history• Group disparities project• Reflective essays and discussion• Individual patient care (e.g.

interpreters) and policy (e.g. Medicare)

• Advocacy Vela et al. JGIM 2008; Vela et al. JGIM 2010.



Stratified Data and Cultural Competency Training Alone

Do Not Improve Clinical Performance Measures

Disparity data interventions helpful but not sufficient

Knowledge/attitude interventions helpful but not sufficient - Sequist TD et al. Ann Intern Med 2010



Hillary Clinton, Black Lives Matter, and Movement Advocacy



Hillary Clinton and Black Lives Matter

“You can get lip service from as many white people you can pack into Yankee Stadium and a million more like it who are going to say: ‘We get it, we get it. We are going to be nicer,’ ” she says. “That’s not enough, at least in my book.”

NY Times. Aug. 19, 2015

“I don’t believe you change hearts,” Mrs. Clinton says, summarizing her basic view of social policy movements. “I believe you change laws, you change allocation of resources, you change the way systems operate.”



Roadmap Step 2 Implement basic quality

improvement structure and process – Quality culture– Quality improvement team– Goal setting and measuring– Local champion– Leadership support



Roadmap Step 3

Make equity an integral component of quality improvement efforts



IOM Model of Quality

Crosscutting

Dimensions

EQUITY

VALUE

Components of Quality Care

Type of Care

Chronic condition management

Acute

Treatment

Preventive

Care

Effectiveness

Safety

Timeliness

Patient/family-centeredness

Care Coordination

Health Systems Infrastructure Capabilities

Access

Efficiency

Crosscutting

Dimensions

EQUITY

VALUE

Components of Quality Care

Type of Care

Chronic condition management

Acute

Treatment

Preventive

Care

Effectiveness

Safety

Timeliness

Patient/family-centeredness

Care Coordination

Health Systems Infrastructure Capabilities

Access

Efficiency



Roadmap Step 4 Design intervention(s)

– Determine root causes– Consider 6 levels of influence– Review literature– Learn from peers– Consider specific interventions



Roadmap Step 4 Design intervention(s)

– Determine root causes Process mapping Talk to target population, not just proxies

– Minority providers may not be proxies for the target population



Conceptual Model

Provider

Patient

Financing / Regulation / Accreditation

Health CareOrganization

Person

Community

Process

Outcomes

Access

Chin MH et al. Med Care Res Rev 2007

Chin MH & Goldmann D. JAMA 2011



6 Levels of Influence: Cultural Competency, Language Access, Health Literacy Policy:

Clinical performance standards – reimburse.Structural measures of culturally competent organization – e.g. interpretersClinical outcomes

Equity index tools to rate organizationsMandated through legislation



6 Levels of Influence Health Care Organization: Diversity, Inclusion, and Equity

initiativesEquity as a true strategic priority

Senior leadershipResources and core team to

facilitate and help move mountains within organizations



6 Levels of Influence Microsystem: Integration of language

services and interpreters into care team; make easy to access for providers

Provider: Working with interpreters; Cultural competency training; Shared decision making training



6 Levels of Influence Patient/Family: Patient

empowerment; Shared decision making training; Easy access to language services

Community: Community empowerment; community health workers; Social determinants of health



Roadmap Step 4 (Cont.) Evidence-based strategies

– Multifactorial attacking different levers– Culturally tailored QI– Team-based care– Families and non-health partners– Patient navigators– Interactive skills-based

training

http://mcr.sagepub.com/current.dtl



Roadmap Step 5 Implement, evaluate, and adjust

intervention(s)



Consolidated Framework for Implementation Research

Intervention (relative advantage) Outer (external incentives) Inner (culture) Individuals (beliefs) Process (plan, execute, evaluate)

Damschroder et al. Implement Sci 2009; 4:50.



Behavior Change Theory Beliefs and knowledge

– Why innovations are good Social norms

– It’s the culture / QI collaboratives Environmental factors

– Incentives Self-efficacy

– Coaching / QI collaboratives



Motivation Intrinsic

– Professionalism– Do the right thing

Extrinsic– Financial– Other rewards



Roadmap Step 6 Sustain intervention(s)

– Institutionalization Culture, incentives, integrate into daily

operations– Societal Business Case

Direct medical costs - $229 billion 2003-2006

Indirect costs - $1 trillion 2003-2006 Healthy national workforce – US Census

Bureau– 2050 – Hispanic 30%, Black 13%, Asian 8% Laveist TA 2009; US Census Bureau 2008.



Where’s the Business Case?



Roadmap Step 6 Sustain intervention(s)

– Values – Right thing to do– Business Case – Align policy incentives

Global payments – Accountable care organizations (ACOs), bundled payments

Population health Pay-for-performance Link community & health care system - CDC,

HHS Community needs assessment for non-profit

hospitals



RWJF Reducing Health Care Disparities Through Payment and Delivery

System Reform

Program Office at University of Chicago

Delivery system intervention Payment reform

– Pay for performance– Global payment– Shared savings



Heckler Report 1985



CMS (Medicare & Medicaid)Align the Financial

Incentives Require public reporting of stratified disparities data

Strengthen incentives for prevention and primary care– Global payment / shared savings– Update MD RVU payment schedule – cognitive – Encourage intersectoral partnerships

Pay for reducing disparities– Include equity accountability measures in

payment programs



Align the Financial Incentives 2 Align equity measures across public &

private payors Take care of safety net providers

– Adequate payment– Calibrate DSH cuts to insurance

expansion– Support for quality improvement– Risk adjustment to create level playing

field Conduct payment and delivery demo

projects Have explicit equity lens - payment and QI



Leadership Matters

“Leadership matters. It is our professional responsibility as clinicians, administrators, and policymakers to improve the way we deliver care to diverse patients. We can do better.”

Chin MH. NEJM 2014; 317:2331-2.

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson...

Documents

Transcript of Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson...