Integrated Framework for Reducing Racial and Ethnic Disparities in the Quality of

Health Care

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

University of Chicago, Institute for Healthcare Improvement

Roadmap

Context and problems in current efforts to reduce disparities in health care quality

Conceptual models for reducing disparities

Evidence on disparity interventions

6 key components for reducing disparities

Implications for funders

Exercise: Advice to AHRQ

Promising Time

Increased public awareness of disparities

Health reform legislation will increase collection of race, ethnicity, and language data

Increased motivation for providers and health care organizations to address disparities

An opportunity to move from description and complaint to action

Problems and Gaps

Lots of research on the magnitude of disparities, but relatively little work on interventions to reduce disparities

Many providers, organizations, and policy makers do not know where to start to reduce disparities

Despite language encouraging proposals on vulnerable populations, many public and private funders receive few applications

Models, Models, Models

Models can inform approaches to disparities, but….

Models must be customized to address the unique underlying causes of disparities directly, but….

Customized solutions are sparse, therefore….

The nation’s research agenda must be directed at testing interventions that address disparities specifically

Level of Engagement Model• Patient/Person• Provider• Microsystem - small unit of care delivery• Organizations that house or support

microsystems• Communities and regions that span care

delivery, prevention, and health promotion for populations

• Environment of policy, payment, regulation, accreditation

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

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Organization of Health Care

Wagner

Planned Care Conceptual Model

Finding Answers: Disparities Research for Change

www.SolvingDisparities.org

New IOM Framework

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

RWJF Finding AnswersConceptual Model

Chin et al. Med Care Res Rev 2007; 64:7S-28S

Provider

Patient

Policy / Payment / Regulation / Accreditation

Health CareOrganization

Person

Community

Process

Outcomes

Access

Systematic Reviews

Reviewed 200+ articles

Condition-specific Cardiovascular disease

Diabetes

Depression

Breast cancer

Cross-cuttingCultural leverage

Pay-for-performance incentives

FAIR Database

Common Successful Interventions from Systematic Reviews

Multifactorial interventions that address multiple leverage points along a patient’s pathway of care

Culturally tailored QI more than generic QI

Nurse-led interventions with multidisciplinary teams and close tracking and monitoring of patients

Chin MH, et al. Med Care Res Rev 2007; 64:7S-28S.

Review of Pediatric Literature (Asthma, Immunizations)

Measure and improve structural aspects of care experience that impact outcomes

Incorporate families into interventions

Integrate non-health care partners into QI interventions

Chin MH, et al. Pediatrics 2009;124 (Suppl 3):S224-S236.

Lessons from RWJF Finding Answers: Disparities

Research for Change Grantees

Knowledge/attitude interventions helpful but not sufficient

Providing disparity data helpful but not sufficient

Context and tailoring are critical

Multifactorial, multitarget interventions

Intervention & the process of implementation

Buy-in, incentives, sustainability, system

Integral Components of Systems Approach to Reducing Disparities

1) Examine your performance data stratified by insurance status, race/ethnicity, language, and socioeconomic status.

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

3) Make reduction of inequities in care for vulnerable populations an integral component of quality improvement efforts.

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

Systems Approach - 2

4) Provide models of care and infrastructural support to enable organizations to improve the quality of care for vulnerable patients.

5) Align incentives to reward providers and health care organizations for providing high quality care to vulnerable populations.

6) Allocate more resources for the uninsured with chronic diseases.

Implications for FundersMove beyond asking applicants simply to show that they have included “priority populations” in their research plan

Ask all quality of care applicants to address specifically how they will reduce known disparities or gaps discovered in the course of the work– Include a measurement plan that stratifies data

appropriately

Design an overall portfolio of grants and grantees that addresses improving outcomes and reducing gaps in diverse populations and settings

Reward applicants who address equity issues

Spheres of Influence for Disparity Interventions

Patient/person

Provider

Microsystem

Health care delivery organization

Community and region

Policy, payment, regulation, accreditation

Which spheres are you addressing or plan to address in your comprehensive, multifactorial approach to reducing an equity gap ?

Example - Care Coordination for Chronically Ill Patients

Patient: engagement, empowerment, mobilization

Provider: engagement, training in health literacy and cultural competency

Microsystem: teamwork, communication, QI, practice redesign, stratified data and real time feedback

Care Coordination for Chronically Ill Patients - 2

Health care delivery organization: communication, coordination, support for patients and families across the continuum, tele-health and monitoring, focus on value and longer term fiscal horizon

Community: activation, mobilization of non-medical resources and supports, attention to social capital and environment

Policy – alignment of incentives and payment to promote the above actions

Exercise: Advice to AHRQ

Request For Applications– Think of your research area– Pick one of the 6 spheres of influence– Write a research question you’d like to be a priority

area 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, what else might AHRQ do, in addition to directing and supporting research on specific topics?

Spheres of Influence for Disparity Interventions

Patient/person

Provider

Microsystem

Health care delivery organization

Community and region

Policy, payment, regulation, accreditation