Health Equity Strategy, Interpretation and Other Levers

for Driving Change

Waterloo Region Immigration Partnership

May 11, 2012

Bob Gardner

One Critical Quality Barrier

• from a resident participating in Wellesley community-based research in St James Town

“Language is a big barrier to us whenever we use any services. When our doctor is on leave then we are unable to visit a different one due to language problem. So we may have to go to a walk-in clinic or emergency. There were no interpreter services. I do not know if they arrange them in hospitals. I couldn’t follow what the doctor said.”

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The Big Picture Problem to Solve: Health Inequities in Ontario

•there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health

•+ major differences between women and men

•the gap between the health of the best off and most disadvantaged can be huge – and damaging

•impact and severity of these inequities can be concentrated in particular populations

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Three Cumulative and Inter-Dependent Levels Shape Health Inequities

1. because of inequitable access to wealth, income, education and other fundamental determinants of health →

1. gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions

2. also because of broader social and economic inequality and exclusion→

2. some communities and populations have fewer capacities, resources and resilience to cope with the impact of poor health

3. because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the health and other systems →

3. these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need

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Key Message

• health disparities are pervasive and damaging • will set out how these disparities can be addressed through

comprehensive health equity strategy • equitable access to high quality interpretation is:

• crucial to breaking down barriers to good health care for newcomers • an indispensable pre-condition for achieving equal opportunities for

good healthcare for all-- especially in an increasingly diverse society • vital to other key components of an effective health system – from

ensuring good quality, patient-centred care, to enhancing access to primary care, and preventing and managing chronic conditions

• building high quality interpretation services is a crucial element of an effective overall health equity strategy

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Health Equity = Reducing Unfair Differences

• Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage

• This concept: • is clear, understandable and actionable • identifies the problem that policies will try to solve • is also tied to widely accepted notions of fairness and social justice

• The goal of health equity strategy is to reduce or eliminate socially and

institutionally structured health inequalities and differential outcomes

• A positive and forward-looking definition = equal opportunities for good health

• Equity is a broad goal, including diversity in background, culture, race and identity

Planning For Complexity

Need to look at how these other systems shape the impact of SDoH:

•access to health services can mediate harshest impact of SDoH to some degree

•community resources and resilience are important

POWER Study: Gender and

Equity Health Indicator Framework

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• even though roots of health disparities lie in far wider social and economic inequality

• how the health system is organized and how care is delivered is still crucial to tackling health disparities

1. it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care

• equitable healthcare and support can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities

2. in addition, there are systemic disparities in access and quality of healthcare that need to be addressed

• people lower down the social hierarchy can have poorer access to health services, even though they may have more complex needs and require more care

• unless we address inequitable access and quality, healthcare and community support services could make overall disparities even worse

Equity Into Health System: Why

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Building Equity Into the Health System: How

1. building health equity into all health care planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach

2. aligning equity with system drivers and priorities • quality improvement, chronic disease prevention and management, wait

times • none of these directions can succeed without taking equity barriers,

social determinants of health and differential risks and needs into account

• aligning with key priorities also enhances chance for success and sustainability of equity focus

3. identifying those levers that will have the greatest impact on reducing health inequities and driving system change

• enhanced primary care • here = how access to interpretation can advance quality and equity

priorities

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Building Equity Into the Health System: How II

4. embedding equity in provider organizations’

deliverables, incentives and performance management

5. targeting some resources or programs specifically:

• looking for investments and interventions that will have the

highest impact on reducing health disparities or improving the

health of most disadvantaged, fastest

• key access barriers – language, culture, availability

• addressing disadvantaged populations – poor, isolated,

racialized, homeless

6. while investing up-stream in health promotion and

addressing the underlying determinants of health

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Equity Into Health System: How III

comprehensive strategy developed in 2008 for Toronto Central LHIN

many recommendations have been acted on:

• LHIN-wide interpretation resources

• equity-relevant patient data

• needs of non-insured

• enhancing coordination of services in disadvantaged neighbourhoods

other LHINs are also prioritizing and moving to address health disparities

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Start From Communities

• goal is to reduce health disparities and speak to needs of most vulnerable communities – who will define?

• can’t just be ‘experts’, planners or professionals • have to build community into core planning and priority setting

• not as occasional community engagement

• but to identify equity needs and priorities

• and to evaluate how we are doing

• how: • many hospital have community advisory panels

• CHCs have community members on their boards

• innovative methods of engagement – e.g. citizens’ assemblies or juries in many countries

• community-based research, needs assessment and evaluation

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And Start From a Solid Strategic Commitment

• need to make equity one of driving priorities for health system and reform • equity and a population health focus are among key principles enshrined in

new Excellent Care for All Act = opening and context

• need clear provincial strategy for equity: • implicit from MOHLTC, but promised ten year strategy has not been released

• equity and population health are in public health standards

• need strategic coherence across health system in approach to equity

• LHINs, CCACs, and other coordinating agencies need to prioritize equity – and many have

• cascading down to all providers prioritizing equity in their overall strategic plans and then into service delivery and resource allocation

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Align Equity With Health System Drivers

• Excellent Care For All Act and quality agenda

• providers have to develop Quality Improvement Plans • hospitals first reported April 2011

• other providers will report in subsequent years

• equity should be developed as one of dimensions to report on – but wasn’t really in first hospital plans

• patient-centred care → means taking the full range of people’s specific needs into account → customizing delivery and quality for more health disadvantaged populations with greater/more complex needs

• improving quality and outcomes also requires addressing equity barriers such as language

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Align Equity With Health System Drivers: Interpretation as a Key Quality Lever

• key things that worry health care EDs and CEOs: • delivering high-quality care efficiently

• reducing risk and enhancing safety

• meeting provincial priorities – wait times, re-admissions, ALCs

• access to interpretation underlies all of these system drivers – consistent evidence that: • poor communication between provider and patient due to language or cultural

barriers can contribute to misdiagnoses and inappropriate prescriptions

• inability to read or understand instructions can lead to medication errors → safety, cost and re-admission implications

• promising indications that good interpretation helps keep people out of hospital and gets them out sooner

• aligning to such drivers and incentives = crucial to build support for interpretation strategy

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Into Practice Through Equity-Focused Planning

• addressing health disparities in service delivery and planning requires a solid understanding of:

• key barriers to equitable access to high quality care

• the specific needs of health-disadvantaged populations

• gaps in available services for these populations

• requires an array of effective and practical equity-focused planning tools

• Health Equity Impact Assessment analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations

• intended to be relatively easy-to-use tool

• essentially prospective, helping plan forward

• HEIA was first piloted in 2009 and is being used by LHINs and providers across the province

• Toronto Central has required HEIA within recent funding application processes, and refreshing hospital equity plans → many hospitals are extending its use

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Success Condition: Equity-Focussed Data

• driving change through better planning and performance management will require better social determinants type data • in addition to language needs, clients’ socio-economic and

cultural background → contributes to building up better picture of community needs

• pilot project underway in 3 Toronto hospitals

• need to analyze impact of interpretation services • comparing re-admission rates, satisfaction, post-hospital

recovery, infection, etc.

→ builds case for investing in interpretation

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Beyond Planning: Embed Equity in System Performance Management

• clear consensus from research and policy literature, and consistent feature in comprehensive policies on health equity from other countries: • setting targets for reducing access barriers, improving health

outcomes of particular populations, etc • developing realistic and actionable indicators for service delivery and

health outcomes • tying funding and resource allocation to performance • closely monitoring progress against the targets and indicators • disseminating the results widely for public scrutiny

• need comprehensive performance measurement and management strategy

• then choose appropriate equity targets and indicators for particular populations/communities

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Success Condition: Effective Equity Targets

• innovative work underway to develop equity indicators – but don’t need to wait

• build equity into existing targets: • reducing avoidable hospitalization and/or readmissions

→ equity target = reduce differences in rates of hospitalization between populations or areas

• many programs assess their services through client satisfaction surveys and look for high and improving satisfaction

→ reduce any differences in satisfaction by gender, income, ethno-cultural background, etc.

• NRC Picker has been translated into several languages

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Getting Specific: Building Language and Interpretation Into Performance Management

• need to define clear equity-focussed expectations: • all providers will deliver sufficient high-quality interpretation

services to meet the needs of the people, communities and catchment areas they serve

• WWLHIN could make that a clear expectation across the system

• then build requirements to meet these expectations – and targets and indicators to measure progress -- into performance management systems: • Quality Improvement Plans = major opportunity • Service Accountability Agreements between LHINs and

providers • accreditation requirements and processes • professional Colleges and other regulatory mechanisms

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Connecting the Dots and Driving Change: Building Interpretation Into Performance Management

• for providers to meet these requirements, they will need to:

• know the language needs of the communities they serve

• this is far more than just the languages of those who come to them for services

• also need to know who is not coming in because of language and other barriers = unmet need

• and it doesn't mean just basic demographic data on languages spoken

• it means what language people are most comfortable receiving care in

• so building interpretation into performance mgmt → providers assessing community needs far better, and integrating that richer knowledge into their planning

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• a promising direction several LHINs have taken up is to require providers to develop equity plans • hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation

in TC • and other providers in Central • CHCs have developed a sector-wide plan in GTA

• these plans are designed to: • identify access barriers, disadvantaged populations, service gaps and

opportunities in their catchement areas and spheres • develop programs and services to address those gaps and better meet

healthcare needs of disadvantaged communities • these provider plans have the potential to:

• raise awareness of equity within the organizations • build equity into planning, resource allocation and routine delivery • pull their many existing initiatives together into a coherent overall equity

strategy • build connections among providers for addressing common equity issues

Use Available Levers: Equity Plans

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Toronto Central LHIN Equity Plans

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Build on Available Opportunities and Resources

• identify key levers or locations for change where better interpretation can have a major impact = • discharge planning • communications around medications

• draw on lessons learned in other LHINs and jurisdictions: • Toronto Central is creating a system-wide phone interpretation

system for hospitals and community providers • specific innovations – ‘phone-on-a-pole’ in UHN hospitals

• adapt resources already developed • several Toronto hospitals have translated material that is

available to others • data collection processes, indicators, etc.

• need to ensure interpretation practitioners and experts are at planning tables

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Never Just Equitable Access, But Quality: Customize Service Delivery

• taking adverse social context and living conditions into account is part of good service delivery

→ can increase risk of mental and physical health illness → fewer resources to cope (from supportive social networks, to good food and

being able to afford medication)

• providers and programs need to know this to customize and adapt care to SDoH and population needs and contexts • focus in acute sectors and ECFAA on patient-centred care → good

communications and provider-patient relationship means taking the full range of people’s specific needs into account → more intensive case management, referral planning and post-discharge follow-up

• in an increasingly diverse society, high quality care = culturally competent care

• beyond acute • health promotion has to be delivered in languages and cultures of particular

population/community • well-baby care has to be more intensive for poor or homeless women

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Not Just at Individual Care Level: Build Equity-Driven Service Models

• drill down to further specify needs and barriers:

• health disadvantaged populations have more complex and greater needs for services and support → continuum of care especially important

• also face greater barriers – e.g. availability/cost of transportation, childcare, language, discrimination → facilitated access is especially important

• e.g. Community Health Centre model of care

• explicitly geared to supporting people from marginalized communities

• comprehensive multi-disciplinary services covering full range of needs

• CHCs, public health and many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to communities facing particular barriers

• innovative coordinating bodies – Hospital Collaborative on Marginalized Populations in Toronto

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Extend That → Address Roots of Health

Inequities in Communities

• look beyond vulnerable individuals to the communities in which they live • have to take Social Determinants of Health into account in planning

and program design • WWLHIN roundtables

• cross-sectoral coordination and planning are key means to address wider SDoH • public health departments and LHINs are pulling together or

participating in cross-sectoral planning tables → Prov should make this an explicit expectation

• Local Immigration Partnerships, Social Planning Councils • explicit SDoH/equity planning networks such as SETo in Toronto

• providing and partnering to provide related services/support such as settlement, language, child care, literacy, employment training, youth support, etc.

• healthy communities strategic approach developed by the former Ministry of Health Promotion and Sport (now in MOHLTC) • focus on community development as part of mandate for many CHCs,

public health and others

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Extending Collaboration →Look for Policy Windows to Intervene to Advance Health Equity

A broad collaborative of leading Toronto health sector institutions and experts came together to:

• ensure that health and health equity were taken into account by the current Commission on the Reform of Social Assistance in Ontario

• define a vision of a health-enabling social assistance system; and

• identify practical actions to implement such a system

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Look Widely for Community Innovation

MiVIA (my Way) • personal electronic health record originally developed for

mostly Hispanic seasonal farm workers in California – and then extended to other vulnerable populations

• supports continuity and efficiency – highlighting the potential of eHealth for even the most marginalized

• the web-based portal and records are in Spanish as well → helping to reduce language barriers

• a vital element of success has been ‘promotores’ --community/peer health promoters – who recruit people into the program, train them on the tools and support them in their own health management

• all services are free

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Look Widely for Community Innovation II

Edmonton Multi-Cultural Health Brokers Cooperative --http://www.mchb.org/ • provides navigation, counselling and other support to people, who

because of language or cultural barriers have trouble making their way through the health system

• they work in some 30 languages and also provide perinatal outreach, home visits, family and seniors support, services for multi-cultural children with disabilities and cultural competence training

• arose from a grass-roots recognition that these barriers were increasingly important but not being addressed

• jointly developed by the local regional health authority, public health and other stakeholders

• many of the brokers were internationally trained providers -- doing this work allowed them to use their skills and become familiar with the provincial system as they waited for recognition of their qualifications

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Conclusions: Driving Equity-Focused Health Care Reform

• driving health care innovation and reform to enhance equitable access and quality is possible: • through solid integrated strategy • systematically implemented – highlighted mechanisms and levers • many innovations underway to draw lessons and inspiration from

• ensuring equitable access to high-quality interpretation will contribute to creating an equitable healthcare system by: • addressing critical barriers -- language and culture are among most important

barriers to equitable access and quality of care • supporting key system drivers – linking interpretation to system priorities like

safety, quality, managing ER, ALC and other bottlenecks, risk management, mental health, chronic conditions

• enhancing impact of innovation – new ways to reduce barriers such as language and culture are necessarily part of wider quality improvement

• making connections – where building interpretation services intersects with – and underpins – an overall equity strategy

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Further Resources

amongst a wide literature, two useful starting points are:

• the Disparities Solutions Center: • out of Massachusetts General Hospital, Harvard and other

leading Boston institutions

• range of evidence-based resources for embedding equity in service delivery and organizational best practices, including a guide for hospital leaders http://www2.massgeneral.org/disparitiessolutions/resources.html#imqual

• Access Alliance Multicultural Health and Community Services : • a range of research reviews and resources on newcomer health

• literature review on the risks and costs of not providing health care interpretation http://accessalliance.ca/sites/accessalliance/files/documents/Lit_Review_Cost_of_Not_Providing_Interpretation.pdf

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