TRANSFORMING HEALTH CARE THROUGH RESEARCH AND EDUCATION

June 2012

Deborah Bohr, MPHAndy Bostick, MA, MPP

Eliminating Health Care Disparities: Why and How

Session Objectives

• Understand why hospitals must take the lead in eliminating disparities in care

• Learn about the various dimensions of health care disparities

• Review health facts for Robeson County• Explore strategies for collecting REaL data• Learn how to use REaL data to reduce health

care disparities and improve health equity

BACKGROUND ON HEALTH CARE DISPARITIES

Elements of Quality Health Care

• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable

STEEEP Examples

IOM Domain Examples

Safe Central Line infections

Timely Radiology turn-around times

Effective Appropriate discharge meds

Efficient Average length of stay

Equitable ???

Patient Centered Patient/employee satisfaction

Disparities in Health Care

• Systematic review of a large body of research found significant variation in the rates of medical procedures by race, even when insurance status, income, age, and severity of conditions were comparable

• Findings indicated that minority patients were less likely to be given appropriate cardiac medications or to undergo bypass surgery, and are less likely to receive kidney dialysis or transplants. Conversely, minority patients were more likely to receive such as lower limb amputations for diabetes and other conditions.  

Disparities in Health Care

• Disparities still exist:

• African Americans received substandard care relative to Whites for 41% of quality measures

• Asians and American Indians and Alaska Natives received substandard care relative to Whites for about 30% of quality measures

• Hispanics received substandard care relative to non-Hispanic Whites for 39% of measures

Causes of Health Care Disparities

• Poor provider-patient communication• Patient mistrust• Stereotyping and bias• Access to evidence-based practice

National Call to Action to Eliminate Health Care Disparities

• Joint effort of the American College of Healthcare Executives, American Hospital Association, Association of American Medical Colleges, Catholic Health Association of the United States, and National Association of Public Hospitals and Health Systems to eliminate health care disparities

• Goals include:• Increase the collection of race, ethnicity and language

preference data• Increase cultural competency training for clinicians and

support staff• Increase diversity in governance and management

ROBESON COUNTY POPULATION FACTS

Robeson County Population Composition

29.00%

24.30%

38.40%

0.70% 0.10% 2.50%

2010 Racial Demographic Data

White African American/Black American Indian and Alaska NativeAsianNative Hawaiian and Other Pacific IslanderTwo or more races

Robeson County Population Composition

8.1%

91.9%

2010 Ethnic Demographic Data

Hispanic or LatinoNon-Hispanic

Racial Differences in Health Care Access

From NC Center for Health Statistics

Racial Differences in Chronic Disease Incidence

From NC Center for Health Statistics

Racial Differences in Mortality Rates

From NC Center for Health Statistics

WHY ADDRESS HEALTH CARE DISPARITIES?

Ethical Case

• All medical centers and their staff want to provide the same quality of care to ALL their patients

Business Case

• Quality differentials can affect HCAHPS Scores, which has implications for hospital revenue under value-based purchasing and pay-for-performance models

• Disparities in care can be costly to hospitals as they contribute to the following:• Extended length of stay• Preventable re-admissions• Hospital-acquired conditions

Risk Management Case

• Medical errors• Poor or inadequate informed consent• Discounting pain and suffering through

miscommunication• Failure to recognize or take into

account the patient’s cultural, religious, or ethnic beliefs

Legal Case

• Section 4302 of the Affordable Care Act of 2010

• Medicare Improvements for Patients and Providers Act of 2008

• Title VI of the Civil Rights Act of 1964• Section 504 of the Rehabilitation Act of 1973• Title II of the Americans with Disabilities Act

of 1990

Quality Case

• SAFETY• Communication difficulties may lead to misdiagnosis

and inappropriate treatment and limit the process of truly informed consent

• EFFECTIVENESS• Minority patients tend to receive fewer key

diagnostic and therapeutic procedures

• PATIENT CENTEREDNESS• Minority patients are more likely feel they will

receive unequal treatment and are less satisfied with quality of care they receive

• TIMELINESS• Minority and LEP patients receive less timely care

which may lead to differences in quality

Accreditation and Regulation Case

• Joint Commission• National Quality Forum• Community benefit and not-for-profit

status

Current Realities, however…

• Sociocultural barriers:• Language and nonverbal

communication• Health practices and beliefs• Role of family members in health

care decision-making• Patient knowledge and expectations

of health system

Beginning the Journey…

The quest to eliminate health care disparities begins with the following:

• Leadership buy-in• Understanding the health needs of the

communities you serve• Incorporating this goal into your overall

quality improvement and strategic plans

REDUCING DISPARITIES THROUGH THE USE OF REAL DATA

What is REaL data?

• REaL data refers to the following patient demographic information:• Race• Ethnicity• Primary Language

Why Define Race? The purpose of defining race is to provide common language to promote uniformity and comparability for the collection and reporting of race and ethnicity.

What is Race?

“ (Race) reflects self-identification by persons according to the race or races with which they most closely identify. These categories are sociopolitical constructs and should not be interpreted as being scientific or anthropological in nature. Furthermore, the race categories have both racial and national-group origins.”

(Source: National Center for Education Statistics Institute of Education Services; http://nces.edu)

OMB Race Categories• The Race Categories are:

• American Indian or Alaska Native• Asian• African American or Black• Native Hawaiian or Other Pacific Islander• White

Useful, if not Perfect• The OMB Categories are not perfect. The race and ethnic categories were developed by the federal government to be able to monitor and help prevent discrimination in housing, education and other areas.

• The U.S. Census uses these categories to track the rapidly changing demographics in the U.S.

OMB Race Categories Defined

• American Indian or Alaskan Native: a person having origins in any of the original people of North and South America (including Central America) and who maintains tribal affiliation or community attachment.• Asian: A person having origins in any of the original peoples of Far East, Southeast Asia or Indian subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

OMB Race Categories• African American or Black: A person having origins in any of the black racial groups of Africa.

• Native Hawaiian or Other Pacific Islander: A person having origins in Hawaii or Pacific Islands not specified in the Asian racial category, e.g., Micronesia, Fiji, Tahiti

OMB Race Categories• White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

HRET modification—Added Category:• Multiracial: A person having origins in more than one of the above categories. (Some organizations allow the coding of up to 3 races.)• Declined• Unavailable (patient incapacitated)

What is Ethnicity?Ethnicity is a term which represents social groups with a shared history, sense of identity, geography, and cultural roots which may occur despite racial difference.

Defining Ethnicity

• Consider Puerto Ricans as an example of an ethnicity. Many Puerto Ricans represent various races.

• Ethnicity shapes a group's culture - the food, language, music, and customs.

• For many patients, nationality or heritage are synonymous with ethnicity.

Why We Need Subpopulation Data

• Race is a broad category. For example, Native Hawaiians and Other Pacific Islanders comprise more than 25 diverse groups with various historical backgrounds, languages, and cultural traditions.

• Research has documented different health risks and health status within smaller population groups, e.g., Puerto Rican individuals versus Honduran individuals. Researchers need data on subgroups or ethnicity.

Ethnic Categories within Race• American Indian or Alaskan Native

• Hopi, Navaho, Cree, Lumbee

• African American/Black• Ethiopian, Kenyan, Dominican,

Haitian, etc.

• White• European, Middle Eastern, Israeli,

French, Irish, North African

Ethnic Categories within Race

• Native Hawaiian or Other Pacific Islander• Polynesian, Samoan, Fijian, etc.

• Asian• Asian Indian, Thai, Korean, Pakistani, etc.

• Multi-ethnic/Multiple, Unavailable, Declined

English Proficiency• How would you rate your ability to speak English?

• Excellent, very good, good, fair, poor?

• Some hospitals collect these data via drop-down screens like race and ethnicity by registration or admitting staff

Language Preference Questions• What language do you feel most

comfortable speaking?• In what language would you prefer to

receive written materials?• For minors, ask these questions of

parents or guardians• These data are recorded via drop-down

screens like race and ethnicity by registration/admitting staff

Language Preference Tools

Language Preference Tools• “I-Speak” cards and point-to posters help staff determine language preferences of LEP individuals (A Patient-centered Guide to Implementing Language Services Across Services in Healthcare Organizations, www.omhrc.gov/Assets/pdf/Checked/HC-LSIG.pdf)

Deaf and Hard of Hearing Populations• Effective communication is equally important in this population; miscommunication can lead to misdiagnosis or delayed treatment.• Many can speak even though they cannot hear.• People who are deaf or hard of hearing use a variety of ways to communicate.

Deaf and Hard of Hearing Populations• Hospitals must provide a variety of services and aids, depending on abilities of the person:

• Sign language interpreters (various)• Oral interpreters • Cued speech interpreters • CART—Computer Assisted Real-time Transcription

COLLECTING REAL DATA

Explaining Why to the Patient• Sample scripts are provided in subsequent slides:

• Community responsiveness • Quality of care • Cultural competence• A combination of the above

Community Responsiveness RationaleWe want to know your race, ethnicity, and preferred language to help us develop services to meet the needs of all the populations we serve.

Quality of Care RationaleWe want to make sure that all of our patients get the best possible care. We would like to ask you to tell us your race, ethnicity, and preferred language so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality of care.

Cultural Competence RationaleWe want to know the race, ethnicity and preferred language of each of our patients to help us provide care that is respectful of everyone’s cultural background.

Combination Rationale We would like to know your race, ethnicity and preferred language. This will help us in a couple of ways. It will help us… and … . (For example, it will help us provide care that respects your cultural background and will help ensure that we provide the most appropriate care and services to all our patients.)

Handling Patient Responses

• Some patients will question why they are being asked for their ethnicity and race.

• They will have questions and comments.

• We want you to feel comfortable answering whatever questions patients ask.

Patient Response Matrix

• The Patient Response Matrix is based on actual patient responses other hospitals have received to race/ethnicity questions.

• The matrix is intended to be used as a tool to help you respond in the best possible manner.

• You may have more examples to add and incorporate into the training of new staff in coming months.

Patient Responses—Routine

Patient Response Suggested Response Hints Code

“I'm American"

“Would you like to use an additional term for race that is listed on this card?” “I can code American as well (for ethnicity).”  

As patient self-

identifies

"Can't you tell by looking at me?"

“Well, usually I can. But sometimes I'm wrong, so we think it is better to let people tell us.”  

As patient self-identifies

"I don’t know. What are the responses?

“Please look at this card--you can say white, Black or Africa-American, Latino or Hispanic, Asian, American Indian or Alaska Native, Pacific Islander or Native Hawaiian, some other race or any combination of these.“  

 As patient self-identifies

"I was born in Nigeria, but I've really lived here all my life. What should I say?"

“Nigerian is great—we’ll list that as your country of origin as well as your ethnicity.” “Could you also state your race as listed on this card?”

 As patient self-identifies

Patient Responses—Routine

Code Hispanic If patient declines to list a separate race, code Preferred Not to Answer in Race slot.

Code Hispanic

“The federal government has designated Hispanic as an ethnicity. I will record Hispanic as your ethnicity. Do you also want to list as race, as described on this card?”

Thank you.”

“Why isn’t Hispanic a race?”

I am Latino/Latina/Puerto Rican

Up to 3 races 

 

“Many people are multi-racial and you can provide me with up to three races that you see on this card.”

I am more than one race—how many can I list.”

N/A

 

“Administrators will see these data and researchers may use non-patient identified data for their studies. No one else will see these data.”

“How will this information be used?”

CodeHintsSuggested ResponsePatient Response

Returning Patients with Incomplete Data

Patient Response Suggested Response Code Hint

A patient returning for care with the “Preferred Not to Answer” code.

None—skip the race and ethnicity questions

N/A—already coded 

Don’t ask again

 

A patient returning for care with the “UN” or "Unable to provide information" code.

Proceed to ask for the information per routine

   

Tougher Questions Patient Response Suggested Response Code Hint

"I'm Human“ “Would you prefer not to answer? If so, that is fine.”

Preferred Not to Answer or Declined

Do not say

Refused

"It's none of your Business"

“I'll put down that you prefer not to answer, which is fine.” “ “

"Why do you care? We're all human beings“

“Well, it is important for our organization to know all of the different populations we treat in order to provide the most appropriate services and the most individualized care.”

“DON'T SAY: I'll just code as a refusal

“

Tougher Questions

Patient Response Suggested Response Code Hint

What do you mean this is part of your patient-centered care approach?

“Everyone is unique and we want to be sure that we know as much about you as possible in order to individualize your care.”

If patient declines further information, code Preferred Not To Answer or Declined  

"Who looks at this?" “The only people who see this information are registration staff, administrators for the hospital and the people involved in quality improvement and oversight.”

“ 

 

"Are you trying to find out if I'm a US citizen?“

“No. Definitely not. Also, you should know that the confidentiality of what you say is protected by law.”

“ 

 

Top FAQs

• Why are data being collected about race, ethnicity and language?• This information helps us understand

the various patient populations we serve. We want to provide the best care to all our patients.

• It is also required by agencies that oversee the care hospitals provide.

Top FAQs

• How will data on race, ethnicity and language affect my care?• Your care will meet the highest

patient care standards. Information about race and ethnicity will help us… this answer will depend on the rationale that the organization selects.

Top FAQs• I am an American citizen; why are race, ethnicity and preferred language being asked?

• This information helps us to better understand our various patient populations, provide more culturally competent care, and comply with federal, state and accrediting agencies.

Top FAQs

• What is the difference between race and ethnicity?• Race reflects self-identification by

persons according to the race or races with which they most closely identify. Ethnicity is a term which represents social groups with a shared history, sense of identity, geography and cultural roots which may occur despite racial differences.

Top FAQs• Why aren’t more races listed?

• A federal working group came up with the list to meet the needs of 30 very diverse federal agencies. The rationale was to have a relatively short list of races and to allow for a much greater list of ethnicities to recognize unique religious, cultural and geographic characteristics.

Top FAQs• What is the difference between “Hispanic” and “Latino?”• There is no difference. OMB accepts Hispanic or Latino. However, for ease of coding our organization has chosen Hispanic. If patient responds “Latino,” code as “Hispanic.”

Top FAQs

• Why isn’t Hispanic a race?• The Federal government decided that

some individuals of the White, Indian (North, Central and South American), and Black races would consider themselves Hispanic because they speak a common language (Spanish) and have a common cultural heritage or ethnicity. It was decided to consider Hispanic an ethnicity, rather than a race. However, many individuals will self-identify their race as Hispanic.

Top FAQs

• Why is “Pakistani” considered Asian and not Middle Eastern?• There is no Middle Eastern race in

order to limit the number of different races. This illustrates the importance of collecting ethnicity information as well as race information. Identifying “Pakistani” as the ethnicity tells us much more than “Asian” as a race.

Monitoring Progress• Your supervisor will meet with you as a group or one-on-one to ask:

• how your patients are responding to be asking their race and ethnicity, and • how you feel the process is working—what’s working and what could be improved.

Monitoring Progress • Your supervisor will also be monitoring the number of Unknowns to determine if some staff are having more difficulty than others obtaining race, ethnicity and preferred language.

SRMC’S DATA COLLECTION PRACTICES

Physician Services Data Collection

Medical Center Data Collection

Home Health/Hospice Data Collection

UTILIZING REAL DATA TO REDUCE DISPARITIES

Tailoring Interventions

• If disparities in outcomes are discovered, design culturally-tailored interventions

Monitoring Quality of Care OutcomesREaL data should be used to measure the following quality differentials:

• Clinical outcomes• Patient satisfaction• Process measures

Sample Dashboard: Colorectal Cancer Incidence Rate by Race/Ethnicity

Cases per 100,000 population

From Santium Hospital

Sample Hospital Equity Report

From RWJF

Other Sample Dashboard Topics

• Hospital Quality Alliance Measures (Process Measures):• AMI, HF, Pneumonia, SCIP, HCAHPS

• NQF-endorsed Standards for Serious Reportable Events

• AHRQ measures• Cardiovascular, Cancer Outcomes*

* Where many medical centers start

CASE STUDIES

Montefiore Medical Center

Objective InterventionsStandardize REaL collection Train registration staff and modify

Information systems

Improve AMI & CHF care for all Montefiore patients

Patient and provider centered materials, improvement methods

Evaluate quality of care by demographic group

Monthly reporting of AMI and CHF measures by demographic group; data analyzed by Quality Dept.

Improve communication with post-discharge providers

CHF-specific discharge planning

New York-Presbyterian

OVERVIEW: Serves predominantly Hispanic community with high rates of asthma, diabetes, heart disease and depression. ACTIONS: Established work group to improve care coordination and culture competency through 4 strategies: 1) Patient-centered medical homes focused on diabetes, CHF, asthma and depression; 2) Centralization of call center functions such as scheduling, test results, and follow-up for 7 outpatient sites; 3) Employment of bilingual and bicultural community health workers and navigators in medical homes and in emergency departments; and 4)Implemented 4-hour training program to build workforce better able to address linguistic, culture and health literacy needs . Physicians receive training with patient-based cross-cultural care, which assists with cultural competency and communication with patients and families. Physicians become more aware of their patients and their own perceptions. RESULTS: As of May 2011, 600 employees rec’d cultural competency training. Collaborative helped decrease # ED visits for ambulatory-sensitive condition by 9.2 %

Baylor Office of Health Equity

OVERVIEW: Baylor’s Office of Health Equity (OHE) aims to reduce variation in health outcomes among it diverse patient populations. Diabetes is a severe epidemic & more than 2X as likely to occur in minority populations. REaL data analysis indicated disparities in diabetes management within Baylor’s primary care practices. ACTIONS: OHE developed a Diabetes Equity Project (DEP) to reduce disparities in diabetes care and outcomes in nearby Hispanic com-munities. Enrollment began 9/09. Steps taken: 1) Community health worker recruitment and training, 2) Building on local clinic partnerships & integrating community health workers into Baylor’s overall care coordination strategy, and 4) developing electronic diabetes registry to track patient metrics and facilitate disease management communication between community health workers and primary care clinicians. RESULTS: > 800 patients enrolled; A1C values improving, suggesting sustainable diabetes control can be achieved for participants who previously had poor control by augmenting “usual care” with community health worker-led patient education & advocacy.

Communication Suggestions

• Community leaders & community meetings• Hospital Newsletters• Local newspaper articles, TV news• Targeted brochures to local households• Posters, table-top signs in Admitting• Laminated cards for registrants to hand out• On medical center Web site• Community focus groups

Using REaL—Leading Practices

1. Use equity dashboard to report org’l performance

2. Inform & customize language translation services

3. Review performance indicators such as LOS, admissions and avoidable readmissions

4. Review process of care measures

5. Review outcomes of care

6. Analyze provision of certain preventive care

7. Analyze patient satisfaction scores

Getting Started

What Leadership Can Do:• Understand your own attitudes and skills—

start with self-assessment tool • Engage the communities you serve &

understand your community’s needs• Standardize REaL data collection• Work with outside experts to begin to analyze

process and outcome data on 1 diagnosis, e.g., cardiovascular care, stratified by race once REaL data collection in place

Resources

• Massachusetts General Hospital Disparities Solutions Center• http://www2.massgeneral.org/disparities solution/guide.html

• Expecting Success: Excellence in Cardiac Care• http://www.rwj.org/pr/product.jsp?id=36180

• HRET Disparities Toolkit• http://www.hretdisparities.org/

• RWJF- Creating Health Equity Reports• http://www.rwjf.org/pr/product.jsp?id=29173

• Hospitals in Pursuit of Excellence• http://www.hpoe.org

QUESTIONS?

Contact Us

• Deborah Bohr• dbohr@aha.org

• Andy Bostick• nbostick@aha.org