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Case Studies on Organizational Efforts to Address Disparities
Joseph R. Betancourt, MD, MPH, Director
Alexander R. Green, MD, MPH, Sr. Scientist
Robin M. Weinick, Ph.D., Associate Director
Outline
An Action-Oriented Response to Unequal Treatment:
The Disparities Solutions Center
Culturally Competent Disease Management:
The Chelsea Latino Diabetes Project
Monitoring Quality and Disparities in Care:
The MGH Disparities Dashboard
Crossing the Quality ChasmInstitute of Medicine, 2001
A Useful Lever
Quality can be achieved if health care
systems are:SafeEffectivePatient CenteredTimely EfficientEquitable
Racial/Ethnic disparities
consistently found across a wide
range of health care settings
(managed care, public/private
hospitals, teaching/community,
etc.), disease areas (CVD, Ca, HIV,
DM, etc.) and clinical services, even
when various confounders are
controlled for (i.e. SES, insurance
status, stage of presentation, and
comorbidities, among others).
IOM’s Unequal Treatmentwww.nap.edu
Recommendations
Increase awareness of existence of disparities
Address systems of care– Support race/ethnicity data collection, QI, EBG, teams, comm outreach
– Improve workforce diversity
– Facilitate interpretation services
Provider education
– Cultural competence, Clinical Decisionmaking
Patient education (navigation, activation)
Research
– Promising strategies, Barriers to eliminating disparities
Barriers to Change
Absence of an action-oriented research agenda– Questions with policy/practice relevance
Little translation of research to policy/practice– Many academic research centers, little funds for dissem/translation
– Research may not meet stakeholder needs
No coordinated political/policy strategy
– Scattered legislative response to IOM Report Unequal Treatment
Minimal efforts focused on education, training, and leadership
– Lack of leadership despite incredible demand
Marginal involvement of community
– No centralized voice to inform process of change or encourage activism
IOM’s Unequal Treatment
A Model for Action:The Disparities Solutions Center
The Disparities Solutions Center will develop and implement strategies that advance policy and practice to eliminate racial and ethnic disparities in health care both locally and nationally.
Accomplished through…
1. Action-Oriented Service and Scholarship
2. Leadership Development
3. Translation into Policy and Practice
Focus Areas and Activities
Translation to Policy/Practice
Research/Evaluation Leadership Development
-Leadership Development on Health Policy, Disparities, Cult Competence
-Focus on various levels of trainees (UG, Grad, Fellows, Faculty)
* Will recruit Scholars/Fellows
-”Rapid Response” research on Disparities
-Assists to identify, disseminate and catalyze research
* Will recruit Scholars/Fellows
-Translate research to policy/practice
-Assist in development of nat’l agenda
ID’s research needs for stakeholders and brings research to
stakeholders
Research/evaluation on education/training, and education/training on
research
Leadership development for practice /policy change
and implementation
Community Benefits
The Disparities Solutions Center
Working with hospitals, health plans, PO’s, states, cities, foundations
Current Projects:– Boston Public Health Commission– Blue Cross-Blue Shield Foundation of MA– State of Delaware– The California Endowment– Robert Wood Johnson Foundation: Leading Change
Major Focus on Disparities Agenda at MGH
Seeking collaborations throughout Harvard
Case Studies on Organizational Efforts to Address Disparities
Culturally Competent Disease Management: The Chelsea Latino Diabetes Project
The Problem
Diabetics at MGH Chelsea doing poorly on several
quality indicators - Latinos worse than whites
Of 1402 diabetics nearly 1/3 of Latinos and >1/4 of
Whites had no HbA1c measured in past 9 months
41% of Latinos and 23% of Whites had HgbA1c > 8
Key groups involved
MGH leadership, DSC, MGH Chelsea, CBO, MGPO
The MGH Chelsea Diabetes Program
A quality improvement / disparities reduction
program with 3 primary components:
• Telephone outreach to increase rate of HbA1c testing
• Individual coaching to address patients’ needs and
concerns regarding diabetes self-management to
improve HbA1c
• Group visits meeting ADA educational requirements
Patient identification and selection
All type II Diabetic Patients at Chelsea identified via
MGH diabetes registry
– Ages 18+
– Latino (Spanish or English) speaking or White (non-Latino,
English speaking)
– Not pregnant
– No cognitive impairment
– Not seen by endocrinology once in past year
– Hgb A1c within past 9 months > 8.0 (those who are tested
via telephone outreach will be asked)
Approx. 356 eligible (246 Latino, 110 White)
Individual coaching
– Initial 1-hour face-to-face meeting
– 3+ Follow-up phone meetings and other support as needed
– Bilingual, non-clinician coach trained by MD and NP
Group visits
– Series of six 90-minute visits
– Both educational and motivational – ADA educational goals
– Will rely on facilitated discussion and peer support
– Conducted by NP and bilingual coach (+/- interpreter)
Coaching / Case ManagementScreening for Risk for Non-Adherence
Explanatory Model
Social Risk for Noncompliance
Fears/Concerns about the Medication
Therapeutic Contracting/Playback
Non-adherence Risk Assessment Tool based on literature review of Sociocultural factors that affect adherence
* Hypertension in Multicultural and Minority Populations: Linking Communication to Compliance.
Betancourt JR, Carrillo JE, Green AR. Current Hypertension Reports. 1999; 1:482-488
Diabetes Coaching / Case Management“ESFT model” to Promote Adherence via Tailored Education / Intervention
How do you understand diabetes?
What do you think will help control your condition?
How do you view your treatment?
• Provide education targeted to patient’s EM • Distribute educational material on
diabetes (langage/literacy appropriate)
Do you have trouble getting your medications (including affording, getting to pharmacy, etc)?
Do you have any specific fears or concerns (side effects, rumors, dose) about your meds?
What other things do you do to treat your diabetes (home remedies, other providers)?
Can you tell me your plan for controlling DM?
• Document and Assist
• Education targeted to patient fear/concern
• Verify other meds/providers, rule out
contraindications, discuss diet; negotiate• Review with patient
Formal Feedback to PCP via EMR
Outcome Measures
HbA1c values and testing rates
Self reported adherence to medications, diet, exercise
Diabetes self-care knowledge
We are interested in what happens to study patients
particularly, but also to quality overall at Chelsea
Also interested in Latino/White disparities
Outcome Measures
Financial feasibility and sustainability
– Taking into account P4P, cost of staff,
reimbursement for group visits
Qualitative analysis of initial “ESFT” interviews
Multiple controls
– Prior 6 months
– Matched controls at another health center
– Eligible non-participants
Case Studies on Organizational Efforts to Address Disparities
Monitoring Quality and Disparities in Care: The MGH Disparities Dashboard
Why a disparities dashboard?
Health care should be– Safe– Effective– Patient-centered– Timely– Efficient
– EquitableInstitute of Medicine,
Crossing the Quality Chasm
2001
Monitoring disparities should be as important as monitoring any
other aspect of quality
(and hospitals monitor quality regularly)
Hospitals monitor quality in the absence of specific QI initiatives
NCQA HEDIS® JCAHO/National Hospital Quality Measures Pay-for-performance contracts Regular internal monitoring
Potential concerns about monitoring disparities
Legal barriers Lack of an agreed upon, validated measure set Difficulties accessing data Risk adjustment/interpreting data Loss of market share
Public reporting and accountability
Quality field is ahead of disparities field National Healthcare Quality Report paired with
National Healthcare Disparities Report Aetna public announcement of collection and
use of data on race and ethnicity
Outline of MGH Disparities Dashboard
Welcome
Purpose
Understanding race/ethnicity at MGH
How race/ethnicity data are currently collected at MGH
Future model for race/ethnicity data collection Categories: White, African American, Latino,
Asian, Other
Data
Data sources used in the report Any statistical issues (e.g., minimum sample
sizes)
What we learned
Highlight 1 or 2 areas where we are seeing few disparities
Highlight 1 or 2 areas where there is opportunity for improvement
Snapshot of diversity of patients
Inpatient care– % of admissions– % of admission starting in emergency department
% of emergency department visits Outpatient care
– % of primary care visits– % of specialty care visits
How are patients distributed among services?
Inpatient– Medical– Surgical– Pediatric– Etc.
Outpatient– Health Center– Non-Health Center
Wait times for new patients
Waiting time for new primary and specialty care appointments
For children and adults
Communicating with our patients
By language– Number of inpatient interpretations– Number of outpatient interpretations– Percent of interpretations that are scheduled and
unscheduled
Inpatient clinical quality indicators
Non-elective readmissions 31 days All National Hospital Quality Measures
– Acute myocardial infarction– Heart failure– Pneumonia
(May add measures for specific services at a later date)
Outpatient clinical quality indicators
Preventive services– Mammogram, Pap smear, colorectal cancer
Diabetes– HbA1c last test date and value– Last LDL cholesterol, microalbumin, and eye exam
(Plan to add asthma when HEDIS measures are available)
Patient experiences with care
Inpatient– Press Ganey
Outpatient– Ambulatory CAHPS
Process
Develop outline and proposed measures Feasibility of data Vetting and consensus building
Distribution
200-300 senior hospital officials Same distribution list as hospital quality
dashboard Distributed by the same office that distributes the
quality dashboard Plans to evolve the Disparities Dashboard to be
the equity component of the Quality Dashboard
Summary
Disparities in health and health care are evident
Some efforts to address disparities currently, mostly piecemeal and at grassroots level
Growing desire among key health care stakeholders for concrete “what to do’s”
Disparities Solutions Center hopes to fill void, in collaboration with others
Organizational efforts at MGH serve as living lab
Acknowledgements
Disparities Solutions Center
– Peter Slavin, Jim Mongan, David Blumenthal, Joan Quinlan
The Chelsea Latino Diabetes Project
– Tom Sterne, Lynne Brodsky, May Chin, Sarah Oo, Andrea Avidano
The MGH Disparities Dashboard
– Elizabeth Mort, Gregg Meyer
617.724.1506
