An Internal Assessment – Health Service Delivery Addressing Disparity in Health and Health Care for Racial and Ethnic Minorities: An Internal Assessment – Health Service Delivery Carla Hayden, R.N.,M.B.A , Director, Office Of Minority Health Michelle L. Groux, M.P.H, Epidemiologist, Office of Assessment and Surveillance Manisha H. Maskay, Ph.D., Director, Division of Planning & Preparedness

The Context and . . . the Mandate Disparities in health status, health care and health outcomes: exist are unacceptable, and must be eliminated!

The journey to eliminate disparities … Is an ongoing process – not a discrete event Requires collaboration from many partners Must be evaluated regularly to assure progress assess impact identify gaps, strengths & opportunities celebrate successes

Racial and Ethnic Health Disparity Circles of Influence Health Care Racism Housing Employment / SES Education Individual Racial/Ethnic Health Disparity

Sadly, health disparities have existed for far too long … Racial and ethnic health disparities have been documented for over a century. In the early 1900’s, Dr. Booker T. Washington, along with other African American leaders, noted poorer health status for African Americans as well as a link between health status and social and economic well-being.

Racial & Ethnic Health Disparities - Columbus As in other U.S. urban areas - disparities in health status and outcomes are persistent & in some cases are increasing: Infant mortality Low birth weight Diabetes prevalence & mortality Sexually transmitted diseases

Health Disparities Columbus Mortality – per 100,000 African American Caucasian All Causes of Death 1,212 927 Heart Disease 319 261 Cancer 264 218 Stroke 89 66 Prostate Cancer 85 26 Diabetes 76 29 Hypertension/hypertensive renal disease 22 5 Homicide 19 4 Infant Mortality (deaths per 1,000 live births) 15 7 HIV disease 10 3 Death data = 1999-2001 Source: ODH Vital Statistics Analysis by: CHD Office of Assessment & Surveillance Prevalence data = 2000 (CHD) or 2002 (PRC/OHF) Kathy, I would suggest including only 10 or so of these for ease of reading and impact Source: ODH, Vital Statistics ’99-’01(Deaths and Births) 2002 Franklin County Health Assessment (Behavior data)

Health Disparities Columbus Health Issues African American Caucasian New cases per 100,000 Syphilis 19 1 Prevalence – % of population Overweight (adult) 68 55 High Blood Pressure (adult) 37 26 Food insecurity (adult ) 12 5 Diabetes (adult) 9 6 Inadequate Prenatal Care (live births) 21 11 Birth weight of less than 5.5 lbs (live births) 12 7 Teen Births--mom less than 18 ( live births) 6 2 Death data = 1999-2001 Source: ODH Vital Statistics Analysis by: CHD Office of Assessment & Surveillance Prevalence data = 2000 (CHD) or 2002 (PRC/OHF) Kathy, I would suggest including only 10 or so of these for ease of reading and impact Source: ODH, Vital Statistics ’99-’01(Deaths and Births) 2002 Franklin County Health Assessment (Behavior data)

Racial Disparities Columbus Infant Mortality Rates IMR* Ratio Difference in IMR = increase of 1.7% a year * Infant Mortality Ratio

Moving forward: Early 1900s 2002 Dr. Booker T. Washington IOM

Moving Forward: In 1999, Congress commissioned an Institute of Medicine study to assess differences in type and quality of healthcare received by minority and non-minority populations.

The IOM Report UNEQUAL TREATMENT: Confronting Racial and Ethnic Disparities in Health Care Relevant findings : Racial and ethnic disparities in health care exist . . . 》They are associated with worse outcomes in many cases – and are therefore unacceptable 》They occur in the context of: - broader historic & contemporary social & economic inequality - evidence of persistent racial & ethnic discrimination in many sectors 》 Many sources may contribute: - health systems - health care providers - patients - utilization managers

Addressing the problem – Our Efforts … Office of Minority Health established - 2000 Key accomplishments: Provided cultural competency education for all staff in 2001 Developed Interpretation/Translation Service Provide ongoing training to clinical staff on how to work with interpreters Provide ongoing educational programs on diversity, cultural issues and addressing disparity

Addressing the problem – Our Efforts … Challenges: Increasing needs/decreasing resources Ensuring cultural competency education for new staff Assuring cultural competency of all staff on an ongoing basis Identifying and addressing problem areas Ongoing evaluation – process & outcomes

Addressing the problem – Our Efforts … Internal Assessment of Columbus Health Department to: - develop a sustainable effort to assess and improve upon the Columbus Health Department’s work related to addressing racial and ethnic health disparities. IOM recommendation 7-1: Collect and report data on healthcare access and utilization by patients’ race, ethnicity, socioeconomic status, and where possible, primary language. Rec 7-2: Include measures of racial and ethnic disparities in performance measurement (JCAHO & NCQA should require it in performance reports.) Rec-7-3: Monitor progress toward the elimination of healthcare disparities. Rec 7-4: Report racial and ethnic data by OMB categories, but use subpopulation groups where possible. Data categories must go beyond the minimum stds to reflect the diversity within racial and ethnic populations, particularly at the local level.

Addressing the problem – Our Efforts … Organizational components to be considered in an internal assessment include: Performance Standards Outcomes Management Performance Evaluation Collaborations Leadership Vision/Mission Staff Composition Policies & Procedures Service Delivery Staff Development & Training

Addressing the problem – Our Efforts … Internal Assessment Phases: I. Health Service Delivery II. Community Health Assessment and Surveillance Activities III. Organizational Cultural Competency

Service Delivery Assessment Objectives: Determine how programs assess the specific needs of racial and ethnic minorities in order to provide the most appropriate care Determine how programs address needs of racial and ethnic minorities Assess strengths and weaknesses in addressing racial and ethnic disparities Identify gaps and opportunities KATHY, I think that if we are going to go into the notes below it should be with the previous slide and probably with less detail. More a mention of this IOM report and the role that the findings and recommendations played in helping to format the info. we collected. -CH: Skim of this base line data, we are really about where we would anticipate in terms of need to have in place consistency of data collection in order to clearly answer the first two objectives. The final report on the assessment will address the last two objectives. IOM recommendation 7-1: Collect and report data on healthcare access and utilization by patients’ race, ethnicity, socioeconomic status, and where possible, primary language. Rec 7-2: Include measures of racial and ethnic disparities in performance measurement (JCAHO & NCQA should require it in performance reports.) Rec-7-3: Monitor progress toward the elimination of healthcare disparities. Rec 7-4: Report racial and ethnic data by OMB categories, but use subpopulation groups where possible. Data categories must go beyond the minimum stds to reflect the diversity within racial and ethnic populations, particularly at the local level.

Service Delivery Assessment Methods: Development of Assessment Tool Reviewed research/practice literature for existing instruments Designed tool to assess direct service programs’ efforts to address racial & ethnic health disparities: Demographic information collected Communication and outreach efforts Services provided Outcomes measured Gaps related to addressing needs of minorities Opportunities for organizational support

Service Delivery Assessment Methods: Pilot Conducted with two programs to assess functionality & inter-interviewer reliability Program Interviews Conducted between July and September 2003 one hour in length with managers of direct service programs 21 programs

Service Delivery Assessment Key Findings - Of 21 programs interviewed: 60% provided “enhanced or specific services focused toward racial and ethnic minority populations” 86% collected data on client race/ethnicity - primarily through self report 24% collected information on clients’ country of birth 29% collected data on primary language of clients 86% collected outcome data - 17% of these considered outcomes by race 67% reported that staff had received diversity or cultural education in the past year

Service Delivery Assessment Challenges: Personnel and time resources Program staff “buy in” need to clearly communicate that assessment process is to improve services & understand client needs vs. monitoring program performance Competing needs balancing requirements of external funders with those of the health department

Service Delivery Assessment Solutions Moving from data to solutions to Eliminate Racial and Ethnic Health Disparities Findings

Service Delivery Assessment: Recommendations and Solutions Data Collection Collect standard socioeconomic data Maintain data electronically Outcome Analysis Analyze outcome data by race and ethnicity

Service Delivery Assessment: Recommendations and Solutions Develop and implement “Guidelines for the Collection of Race and Ethnicity Data,” by Columbus Health Department Clinics and Programs Implement Medical Manager Electronic Records System

Service Delivery Assessment: Recommendations and Solutions Provide services in a culturally and linguistically appropriate manner Implement Federal “Culturally and Linguistically Appropriate Services in Health Care” – CLAS Standards Federal Register: December 22, 2000, Volume 65, Number 247, page 80865-80879

Service Delivery Assessment: Recommendations and Solutions Culturally and Linguistically Appropriate Services in Health Care (CLAS) “The standards for culturally and linguistically appropriate services … proposed as a means to correct inequities that currently exist in the provision of health services and to make these services more responsive to the individual needs of all patients/customers.” Source: Culturally and Linguistically Appropriate Services in Health Care, The Office of Minority Health, U.S. Public Health Service.

Service Delivery Assessment: Recommendations and Solutions Staff Development Cultural competency education and training Mandatory attendance at City of Columbus diversity workshop for all new employees Training for “Working with Interpreters” for all service providers

Service Delivery Assessment: Recommendations and Solutions Ongoing Quality Improvement Service Delivery Assessment to be completed every two years Implement Performance Management System to track outcomes by race & ethnicity

Eliminating Racial and Ethnic Health Disparities - an ongoing journey not a discrete event … … requiring many partners!!!

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