Integrated Framework for Reducing Racial and Ethnic Disparities in the Quality of Health Care Marshall H. Chin, MD, MPH, and Don Goldmann, MD University of Chicago, Institute for Healthcare Improvement

Roadmap Context and problems in current efforts to reduce disparities in health care quality Conceptual models for reducing disparities Evidence on disparity interventions 6 key components for reducing disparities Implications for funders Exercise: Advice to AHRQ

Promising Time Increased public awareness of disparities Health reform legislation will increase collection of race, ethnicity, and language data Increased motivation for providers and health care organizations to address disparities An opportunity to move from description and complaint to action

Problems and Gaps Lots of research on the magnitude of disparities, but relatively little work on interventions to reduce disparities Many providers, organizations, and policy makers do not know where to start to reduce disparities Despite language encouraging proposals on vulnerable populations, many public and private funders receive few applications

Models, Models, Models Models can inform approaches to disparities, but…. Models must be customized to address the unique underlying causes of disparities directly, but…. Customized solutions are sparse, therefore…. The nation’s research agenda must be directed at testing interventions that address disparities specifically

Level of Engagement Model Patient/Person Provider Microsystem - small unit of care delivery Organizations that house or support microsystems Communities and regions that span care delivery, prevention, and health promotion for populations Environment of policy, payment, regulation, accreditation Based on Berwick, Health Affairs 2002;21:n. 3

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Organization of Health Care Wagner Planned Care Conceptual Model

Finding Answers: Disparities Research for Change New IOM Framework

RWJF Finding Answers Conceptual Model Chin et al. Med Care Res Rev 2007; 64:7S-28S Provider Patient Policy / Payment / Regulation / Accreditation Health Care Organization Person Community Process Outcomes Access

Systematic Reviews Reviewed 200+ articles Condition-specific Cardiovascular disease Cardiovascular diseaseDiabetesDepression Breast cancer Cross-cutting Cultural leverage Pay-for-performance incentives FAIR Database

Common Successful Interventions from Systematic Reviews Multifactorial interventions that address multiple leverage points along a patient’s pathway of care Culturally tailored QI more than generic QI Nurse-led interventions with multidisciplinary teams and close tracking and monitoring of patients Chin MH, et al. Med Care Res Rev 2007; 64:7S-28S.

Review of Pediatric Literature (Asthma, Immunizations) Measure and improve structural aspects of care experience that impact outcomes Incorporate families into interventions Integrate non-health care partners into QI interventions Chin MH, et al. Pediatrics 2009;124 (Suppl 3):S224-S236.

Lessons from RWJF Finding Answers: Disparities Research for Change Grantees Knowledge/attitude interventions helpful but not sufficient Providing disparity data helpful but not sufficient Context and tailoring are critical Multifactorial, multitarget interventions Intervention & the process of implementation Buy-in, incentives, sustainability, system

Integral Components of Systems Approach to Reducing Disparities 1) Examine your performance data stratified by insurance status, race/ethnicity, language, and socioeconomic status. 2) 2) Get training for your staff to work effectively with diverse populations. 3) 3) Make reduction of inequities in care for vulnerable populations an integral component of quality improvement efforts. Chin MH. Ann Intern Med 2008; 149:

Systems Approach - 2 4) 4) Provide models of care and infrastructural support to enable organizations to improve the quality of care for vulnerable patients. 5) 5) Align incentives to reward providers and health care organizations for providing high quality care to vulnerable populations. 6) 6) Allocate more resources for the uninsured with chronic diseases.

Implications for Funders Move beyond asking applicants simply to show that they have included “priority populations” in their research plan Ask all quality of care applicants to address specifically how they will reduce known disparities or gaps discovered in the course of the work –Include a measurement plan that stratifies data appropriately Design an overall portfolio of grants and grantees that addresses improving outcomes and reducing gaps in diverse populations and settings Reward applicants who address equity issues

Spheres of Influence for Disparity Interventions Patient/personProviderMicrosystem Health care delivery organization Community and region Policy, payment, regulation, accreditation Which spheres are you addressing or plan to address in your comprehensive, multifactorial approach to reducing an equity gap ?

Example - Care Coordination for Chronically Ill Patients Patient: engagement, empowerment, mobilization Provider: engagement, training in health literacy and cultural competency Microsystem: teamwork, communication, QI, practice redesign, stratified data and real time feedback

Care Coordination for Chronically Ill Patients - 2 Health care delivery organization: communication, coordination, support for patients and families across the continuum, tele- health and monitoring, focus on value and longer term fiscal horizon Community: activation, mobilization of non- medical resources and supports, attention to social capital and environment Policy – alignment of incentives and payment to promote the above actions

Exercise: Advice to AHRQ Request For Applications – –Think of your research area – –Pick one of the 6 spheres of influence – –Write a research question you’d like to be a priority area for the RFA for your research area in that sphere of influence – –If time, write questions for other spheres To reduce disparities in health care quality, what else might AHRQ do, in addition to directing and supporting research on specific topics?

Spheres of Influence for Disparity Interventions Patient/personProviderMicrosystem Health care delivery organization Community and region Policy, payment, regulation, accreditation