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Nancy L. Combs, MA Denise White Perkins, MD, PhDDirector DirectorCommunity Health, Equity & Wellness Institute on Multicultural Health

Friday, October 28, 2011Michigan Minority Health Council, Lansing Michigan

HFHS Healthcare Equity Campaign

OverviewWhat steps has the organization taken to increase awareness of and respond to social determinants of health as it cares for a culturally diverse patient population?How has Henry Ford Health System (HFHS) sought to improve the quality of health services offered to communities of color and to decrease healthcare disparities in their patient population?What strategies has HFHS taken to ensure culturally competent care is provided for minority patients?How has HFHS partnered with the community to address health and healthcare disparities?

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3 Phases

Phase 1: Raise awareness about health and healthcare disparities as we move toward healthcare equityPhase 2: Implement tools to improve cross-cultural communication and collaboration; plan for review of quality metrics by race/ethnicityPhase 3: Integrate into System processes to ensure sustainability and accountability; develop process for continuous monitoring of quality metrics by race/ethnicity and for intervention

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Phase 1: Awareness-Raising

HFHS Manager’s Toolkits: Aug ‘09 & Mar ‘10 Articles in The MonitorVodcastsEmployee-only Facebook pagePresentations to system leadership groupsUnnatural Causes brown bag lunch sessionsUnnatural Causes on HFHS University3.25 CME/CEU Workshop (220 Ambassadors trained!)30 minute online course on HFHS University

Unnatural Causes

Groundbreaking 4-hour PBS documentary initially broadcast March 2008Reframes the national debate over health as a medical detective story solving the mystery of health inequitiesDeeper exploration into the ways social conditions affect health outcomes

Unnatural Causes

http://www.unnaturalcauses.org/video_clips_detail.php?res_id=80www.UnnaturalCauses.org

Projected population growth by race, 2008 – 2050

0255075

100125150175200225

2008 2050

White

Hispanic

African American

Asian

AIAN

Pacific IslanderNum

ber

in m

illio

ns

US Census Bureau, released 8/14/2008

CHANGING DEMOGRAPHICS: Michigan

Race/Ethnicity 1980 1990 2000 2005 % Change

White 85.8 84.2 80.2 80.0 -6.8

Black 13.0 14.0 14.2 14.0 7.7

American Indian

0.5 0.6 0.6 0.6 20.0

Asian/Pacific Islander

0.7 1.2 3.1 3.8 442.9

Multi-Racial N.A. N.A. 1.9 1.6 N.A.

Hispanic 1.7 2.2 3.3 3.8 123.5

Distribution of Michigan’s Population by Race/Ethnicity

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Race/Ethnicity Macomb Oakland Wayne

White 87.6 79.6 52.6

Black 6.6 11.9 40.8

American Indian 0.3 0.3 0.3

Asian/Pacific Islander 3.2 5.3 2.4

Multi-Racial 1.8 1.9 1.7

Hispanic N.A. 3.1 4.9

Distribution SE Michigan Population by Race/Ethnicity, 2006-2008

Race by Zip Code

Source: Thomson Reuters Market Expert Database

% Non-white by Zip Code

76% to 99%51% to 75%26% to 50%11% to 25%3% to 10%

Education* by Zip Code

* % with less than high school education. Source: Thomson Reuters Market Expert Database

Median HH Income by Zip Code

Source: Thomson Reuters Market Expert Database

Health Status by Zip Code

Source: Thomson Reuters Market Expert Database

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DefinitionsHealth disparity refers to differences in health outcome or statusHealthcare disparity refers to differences in the preventive, diagnostic, and treatment services offered to people with similar health conditionsHealthcare equity is providing care that does not vary in quality by personal characteristics such as ethnicity, gender, geographic location, and socioeconomic status

Age-Adjusted Heart Disease Death Rates for Blacks and Whites, 1950-2000

Dea

th R

ates

per

100

,000

Pop

ulat

ion

100

200

300

400

500

600

700

1950 1960 1970 1980 1990 2000

YEAR

WhiteBlack

David Williams, PhD, MPH, Presentation to HFHS January 30, 2009

Dea

th R

ates

per

100

,000

Pop

ulat

ion

100

150

200

250

300

1950 1960 1970 1980 1990 2000

YEAR

WhiteBlack

David Williams, PhD, MPH, Presentation to HFHS January 30, 2009

Age-Adjusted Cancer Death Rates for Blacks and Whites, 1950-2000

10.3

27.532.9

36.3

12.5

21.2

38.7

34

8.3

22.326.627.4

7

19.624.2

26.6

0

5

1015

20

25

3035

40

45

HBP Diabetes Smoking Obesity

Black Males Black Females White Males White Females

Racial and Gender Disparities in Selected Risk Factors for Chronic Disease, Michigan, 2005

Source: Michigan Behavior Risk Factor Surveillance System

Breast Cancer Incidence and Mortality by Race

32.9

113.2123.3

23.7

0

20

40

60

80

100

120

140

Incidence 2003 Mortality 2003

BlackWhite

Age

-adj

uste

d ra

te p

er 1

00,0

00*

Source: Vital Records & Health Data Development Section, Michigan Department of Community Health*Adjusted to 2000 US standard population.

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EvidenceReported significant variation in the rates of medical procedures by race, even when insurance status, income, age, and severity of conditions are comparable. This research indicates that U.S. racial and ethnic minorities are less likely to receive even routine medical procedures and experience a lower quality of health services.

EvidenceFour key themes emerged in the 2010 NHDR:

Healthcare quality and access are suboptimal, especially for minority and low-income groupsQuality is improving; access and disparities are notSome disparities merit particular attentionProgress is uneven

Emergency department (ED) visits in which patients left without being seen, by race (left) and payment source (right), 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006.

More Healthcare Disparities

African Americans are referred less than whites for cardiac catheterization & bypass graftingLatinos & African Americans receive less pain medication than whites for long bone fractures in the Emergency Department & for cancer pain on the floorsAfrican Americans with end-stage renal disease are referred less to the transplant list than whitesVarious healthcare disparities are present as well for certain Asian populations, American Indians and Alaska Natives, Arab Americans, and other communities of color

Institute of Medicine, Unequal Treatment, 2001

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Why do healthcare disparities exist?Health system variables

Complex health systems may be poorly adapted to and difficult to navigate for various cultural groups, especially for those with limited English speaking proficiency or for those with low literacy

Care process variablesIssues related to health providers such as unconscious bias & stereotyping and its impact on decision making; clinical uncertainty due to poor communication

Patient level variablesPatients’ mistrust, poor adherence to treatment and delays in seeking care

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Privilege and ResponsibilityPurpose:

Become more aware of your sources of privilege and power in everyday life and work environment Consider how you might leverage your privilege or power to reduce disparities or health inequities

Instructions:Circle each of the statements that is true for you

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Phase 2: Cultural CompetencyPilot an organizational cultural competency assessment with select departmentsReview current forms and patient education materials for reading level and make recommendations for improvementReview current interpretation & translation services and make recommendations for improvementConduct skills-based cultural competency training for clinicians & non-cliniciansIncorporate culture/language considerations into conflict and grievance reporting and resolution mechanismsWork with community partners on health equity issues

Culturally Competent Health Care: A 3-Legged Stool

Culturally Competent Communication

Language Access

Health Literacy

CULTURAL COMPETENCE CAN LEAD TO:

Increased patient satisfactionIncrease in patients’ healthcare-seeking behaviorMore successful patient communication and educationMore appropriate testing and screeningFewer diagnostic errorsAvoidance of drug complicationsGreater adherence to medical adviceExpanded choices and access to high-quality clinicians

… Reduced racial/ethnic healthcare disparities and improved quality of care

“The Provider’s Guide to Quality & Culture,” Management Sciences for Health, Electronic Resource Center

BEYOND CULTURAL COMPETENCE

“Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique,

to redressing the power imbalances in the patient-physician dynamic, and to developing

mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on

behalf of individuals and defined populations.”

Tervalon & Murray-Garcia, 1998

SOCIAL AND CULTURAL BARRIERS TO HEALTHCAREACCESS

Racial and ethnic disparities in insurance coverage, even when adjusting for incomeDifferences in health practice and abilities to navigate the health systemFear (e.g. illegal immigrants)Mistrust (e.g. Tuskegee Syphilis Study)Language barriersLiteracy barriers

Language Access ServicesIn 2012 Joint Commission requires that:

“The hospital identifies the patient’s oral and written communication needs, including the patient’s preferred language for discussing health care.”“The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient’s oral and written communication needs.”“Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience”

Surveyors from TJC’s last visit mentioned that we need to have more consent forms translated into high-need languages

Language Resources at HFHS

Pacific Interpreters provides telephonic interpretation and translation services

Call 1-800-264-1552Access Code for Ambulatory: 4841

Voices for Health (preferred) and Brombergprovide in-person interpretation services

Policy for use being drafted

Further Learning“Unnatural Causes: Stating the Problem & Finding Solutions”

3.25 CME credits; 3.0 CEU for social workers“Moving Along the Cultural Competence Continuum” (for clinicians)

3.5 CME credits Register for the above at: www.henryford.com/cmeevents (2012 dates TBD)

“Uprooting –isms: Creating a Culturally Competent Organization”December 2nd, 8:30 a.m. – 12 noon, OFP 5C00

Register for the above at HFHS University

HFHS University online courses on healthcare equityHealthcare Equity 101: Social Determinants of HealthCultural Competence: Background and BenefitsCultural Competence: Providing Culturally Competent CareWatch Unnatural Causes in its entirety (4 hours)Watch Crossing Cultures in its entirety (13 minutes)

Website: http://henry.hfhs.org/healthcareequitycampaign

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Phase 3: Sustainability

Integrate changes into System processes to ensure sustainability and accountability; develop process for continuous monitoring of quality metrics by race/ ethnicity/ language

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Common themes:Provision of quality language & translation servicesAddressing literacy/communication needsCultural competency trainingCollection of race/ethnicity/primary language dataUsing data to measure disparities and address them when they are identified

New Regulatory Requirements

Community: Focus Groups

Conducted in partnership with Michigan Roundtable for Diversity & InclusionOrganizations participating in focus groups:

American Indian Health and Family ServicesNative American

APIA VoteAsian and Asian Pacific Islander

Community Health and Social ServicesLatino

Arab Community Center for Economic and Social ServicesArab American

Metropolitan Organizing Strategy Enabling StrengthAfrican American

Access to Care

United Way 211CHASS Clinic Southwest and MidtownCabrini ClinicPrescription Assistance ProgramCommunity based disease managementCharity care

Other Community Based Projects

Brightmoor and Matrix Community Health Resource CentersFaith Community NursingInterfaith Health and Hope Coalition Circles of CareCommunity based screenings

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Remember

“Of all the forms of inequity, injustice in health care is the most shocking and inhumane.”

- Rev. Martin Luther King, Jr.

Questions?