A Unique Health Equity Collaboration Model for State Policy Implementation Carlessia A. Hussein, RN, DrPH, Director Office of Minority Health and Health Disparities Maryland Department of Health and Mental Hygiene March 12, 2013 DiversityRx Eighth National Conference on Quality Health Care for Culturally Diverse Populations Oakland, California

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Maryland Population, 2010 U.S. Census by Race and Ethnicity (45.3%) Minority Source: 2010 Census Demographic Profiles, Department of Planning, Projections and Data Analysis/State Data Center, May

Progress in Disparity Elimination in Maryland  Between 2001 and 2010 the gaps between the Black and White age-adjusted death rates (Black rate minus White rate) were reduced as follows: – For All-cause Mortality, the gap was reduced by 43% – For Cancer Mortality, the gap was reduced by 65% – For Heart Disease Mortality, the gap was reduced by 29% – For Stroke Mortality,the gap was reduced by 6% – For Diabetes Mortality, the gap was reduced by 30% – For HIV/AIDS Mortality,the gap was reduced by 57% 4

Cost of Disparities Hospital Admission Rates by Race and Age, Maryland 2011 MHHD – Office of Minority Health and Health Disparities, DHMH HSCRC – Health Services Cost Review Commission Source: MHHD analysis of HSCRC 2011 hospital discharge data 5

Cost of Disparities (Continued) Hospital Cost of Excess Black or African American Hospital Admissions, Maryland 2011 Source: MHHD analysis of HSCRC 2011 hospital discharge data [11] 6

Maryland Office of Minority Health and Health Disparities (MHHD) Historical Development Background The Maryland General Assembly passed House Bill 86/Senate Bill 177 in April of 2004 that mandated the Department of Health and Mental Hygiene (DHMH) to establish an Office of Minority Health and Health Disparities (MHHD) in the Office of the Secretary. Mission In fulfillment of the Department’s mission to promote the health of all Maryland citizens, the Health Disparities Initiative shall focus the Department’s resources on eliminating health disparities, partner with statewide organizations in developing policies and implementing programs and monitor and report the progress to elected officials and the public. The target ethnic/racial groups shall include African Americans, Hispanic/Latino Americans, Asian Americans and Native Americans. 7

Maryland Plan To Eliminate Minority Health Disparities The Second Health Disparities Plan published by MHHD [First Plan published in 2006] Published in March 2010 – available at Developed through the consultation and work of the Collaborative and wide public input (engaged over 2,500 stakeholders in development process) 8

Maryland Health Disparities Collaborative The Collaborative is charged with assisting the Office of Minority Health and Health Disparities (MHHD) and the Secretary of DHMH in establishing priorities for programs, services and resources for minority health. Established in 2008 in compliance with Maryland Health-General Article, Section , that calls for an advisory commission to assist the Minority Health and Health Disparities (MHHD) Office in carrying out its duties 9

Maryland Health Disparities Collaborative Collaborative Leadership Collaborative is co-chaired by the current DHMH Secretary, Joshua Sharfstein, MD and Donna Jacobs, Esq, Senior Vice President of Governmental and Regulatory Affairs, University of Maryland Medical System Collaborative Members Has over 210 active members Members representing State and Local health leadership, healthcare administrators, community health advocates, faith-based representatives, academic leadership, and includes representatives from diverse geographic locations 10

Maryland Health Disparities Collaborative Collaborative Implementation Plan Intended to move the State of Maryland to take concrete actions that will achieve measurable progress toward the reduction of major health disparities in the State The Health Disparities Plan lays out 5 objectives each with action steps, key stakeholders and measures The objectives align with the National Partnership for Action (NPA) and links to the State Health Improvement Process (SHIP) In August 2011, the Collaborative formed 5 Workgroups that addressed each of the 5 objectives in the Plan These Workgroups developed specific Guidelines and Principles to assist DHMH with the implementation of the Maryland Health Improvement and Disparities Reduction Act of

Maryland Health Disparities Collaborative Five Collaborative Workgroups Awareness – Increase awareness of the significance of health disparities, their impact on the state and local communities, and the actions necessary to improve health outcomes for Maryland’s racial and ethnic minority populations. Leadership and Capacity Building – Strengthen and broaden leadership for addressing health disparities at all levels. Health and Health System Experience – Improve health and health care outcomes for racial and ethnic minorities and underserved populations and communities. Cultural and Linguistic Competency – Improve cultural and linguistic competency. Research and Evaluation (Data) – Improve coordination and use of research and evaluation outcomes. 12

Maryland’s Groundbreaking Health Disparities Legislation The Maryland Health Improvement and Disparities Reduction Act of 2012 (SB 234) History Before passage of the ACA in Congress, Maryland had formed a Health Quality and Cost Council with a charge to take immediate steps to raise the health of all of its citizens. Upon passage of the ACA, the State stepped up its pace to implement Health Reform. One of several recommended actions was to reduce health disparities. The Council formed a Disparities Workgroup to draft actions for the State to enact. The Maryland Office of Minority Health and Health Disparities provided staff support to this diverse group of disparities experts. The subsequent report was submitted to the Administration. The recommendations in the Report became legislation that was passed unanimously in April Purpose The goals of the legislation are to reduce health disparities, to improve health outcomes, and reduce health costs and hospital admissions and readmissions. 13

The Maryland Health Improvement and Disparities Reduction Act of 2012 Provisions 1. Establish Health Enterprise Zones (HEZ) in small geographic areas having very poor health statistics, health disparities and high poverty. The HEZ is eligible for loan repayment assistance, tax credits, capital equipment credits, electronic medical records assistance and participation in the Patient Centered Medical Home program, and funding for four years. 2. Establish and incorporate a standard set of measures regarding racial and ethnic variations in the State Quality Outcomes reports generated by the Maryland Health Care Commission. Include information on the actions taken by carriers to track and reduce health disparities, including whether the health benefit plan provides culturally appropriate educational materials for its members. 3. Require each non-profit hospital in the State to include in their Annual Community Benefits Reports, a description of the hospital's efforts to track and reduce health disparities. 4. Require institutions that offer programs necessary for the licensing of health care professionals in the State to report on their actions taken to reduce health disparities. 5. Two state commissions that work with hospital and health insurer data, shall recommend standards for evaluating the impact of the Maryland Patient Centered Medical Homes on eliminating health disparities. 6. Form a workgroup to develop standards and criteria for cultural competency in medical and behavioral health treatment settings. 14

Collaborative Implementation Guidelines & Principles Provision #1 Health Enterprise Zones (HEZs) Outreach to community-based organizations around the state Identify current and develop comprehensive lists of Community Based Organizations and existing networks with community based outreach Create and pretest outreach messages that are created through community input, focus groups, and in-person discussions with community leaders Create a standard outreach message template and toolkit of resources on the subject matter Use multi-channel marketing strategies Provide Hospitals, larger institutions, and Local Health Departments information on how to effectively partner with CBO’s Identify and collaborate with effective initiatives or programs currently being implemented in high health need areas for community outreach 15

Collaborative Implementation Guidelines & Principles Provision #1 Health Enterprise Zones (HEZs) (continued) Establish a virtual network of community health equity leaders Include community health leaders and their contacts Identify who will be responsible for creating messages, managing the network, and disseminate messages Identify and employ tools and software to disseminate information to large groups Use effective non-IT forms of communication for outreach Provide technical assistance for organizations to apply and achieve both promising practices and evidence-based practices Locate resources for funds for the applications that are not selected 16

Collaborative Implementation Guidelines & Principles Provision #1 Health Enterprise Zones (HEZs) (continued) Evidence-based options for communities and local health institutions and health plans to consider in establishing effective community health programs Interactive webpage of chronic disease evidence-based, promising and best practices Implement a diabetes prevention “Small Steps” campaign to create materials for people at risk for diabetes, using multipronged community outreach Launch a tobacco cessation campaign with advertising campaigns and historical, cultural, and socioeconomic influences targeted to specific groups Promote healthy eating through faith-based programs and peer counseling Recruit barbershops to aid in improving hypertension detection and control, helping black men beat high blood pressure, and controlling cardiovascular disease 17

Collaborative Implementation Guidelines & Principles Provision #1 Health Enterprise Zones (HEZs) (continued) Evidence-based options for communities and local health institutions and health plans to consider in establishing effective community health programs (continued) Assist people released from prison find primary care and navigate the health care system Better use hospital emergency departments to test for HIV, HCV, and other infectious diseases and conditions, and then provide assistance and referrals Promote the Community Health Worker (CHW) movement Manage heart failure more effectively Employ proven effective drug treatment for addiction and combine with a broad community program in housing, medical care, social rehabilitation, job training, and social support Tackle obesity by addressing the social determinants of health 18

Collaborative Implementation Guidelines & Principles Provision #1 Health Enterprise Zones (HEZs) (continued) Successful models of care that address disparities Bright Beginnings of Maryland ( The REsidents Access to a Coalition of Health (REACH) ( S.M.I.L.E. Program (part of the African American Health Program in Montgomery County) ( ( Diabetes Dining Club (part of the African American Health Program in Montgomery County) ( Community Health Partnership (CHP)’s Baltimore Community Health Action Team (B-CHAT) ( 19

Collaborative Implementation Guidelines & Principles Provision #1 Health Enterprise Zones (HEZs) (continued) Use criteria as a guide for assessing the level of cultural and linguistic competence of Health Enterprise Zone applications Include criteria as an appendix to the request for proposals with suggested scoring rubric Areas of suggested criteria include: Community Engagement Patient-Provider Communication and Language Services Workforce Diversity and Training Managerial and Operational Supports Care Delivery Data Collection 20

Collaborative Implementation Guidelines & Principles Provision #2 Standard set of measures regarding racial and ethnic variations in the State Quality Outcomes reports & whether health benefit plan provides culturally appropriate educational materials for its members Adopt the approach of OMB Directive 15 as the overarching shell for Race, Ethnic and Language data collection. Collect Hispanic ethnicity (yes or no response) and Race in categories of White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander (pick all that apply) Collect data on English proficiency and preferred language for healthcare Use the questions in the HHS new data collection guidelines Add to the OMB approach collection of relevant subcategories of the primary racial and Hispanic ethnic groups. Appropriate lists of subcategories for Maryland should be determined by consultation with appropriate minority populations and by reference to subgroup population sizes from the 2010 census Develop a process for obtaining input from the various minority populations and their advocacy groups 21

Collaborative Implementation Guidelines & Principles Provision #2 Standard set of measures regarding racial and ethnic variations in the State Quality Outcomes reports & whether health benefit plan provides culturally appropriate educational materials for its members (continued) Incorporate elements of cultural, linguistic, and health literacy appropriate communication into the health plan evaluation tools and certification processes currently being developed by the Maryland Health Benefit Exchange and the Maryland Health Care Commission Require Maryland health plans to incorporate into their current consumer surveys a standardized subset of supplemental items on cultural competence and health literacy 22

Collaborative Implementation Guidelines & Principles Provision #3 Description of hospital's efforts to track and reduce health disparities in Annual Community Benefits Reports The Health Services Cost Review Commission (HSCRC) is required under of the Health General Article, Maryland Annotated Code to collect information and prepare a Community Health Benefit Report that describes the types and scopes of community benefit activities conducted by nonprofit hospitals Amendments to this legislation in the 2012 Legislative Session now requires HSCRC to add to these report requirements, a description of the Hospital’s efforts to track and reduce health disparities in the community that the hospital serves 23

Collaborative Implementation Guidelines & Principles Provision #4 Report on actions to reduce health disparities by higher education institutions with health care professional licensing programs Consolidate the institution of higher education reporting requirements found in both the Maryland Health Improvement and Disparities Reduction Act of 2012 and HB 679 so that the information for the two reports are submitted by each health profession training program as a single document Consider a reporting format (example provided in final report) 24

Collaborative Implementation Guidelines & Principles Provision #5 Two State commissions that work with hospital and health insurer data, shall recommend standards for evaluating the impact of the Maryland Patient Centered Medical Homes on eliminating health disparities The Maryland Health Care Commission has formed an advisory panel that is examining requirements relating to the Medical Home Program The Health Services Cost Review Commission has convened a Hospital Race and Ethnicity Disparities Workgroup that is looking at the requirements for hospital incentive programs 25

Collaborative Implementation Guidelines & Principles Provision #6 Workgroup to develop standards and criteria for cultural competency in medical and behavioral health treatment settings (MHQCC Cultural Competency Workgroup) Consider specifications to support the implementation of continuing education in cultural, linguistic, and health literacy competency Consider how process measures related to cultural, linguistic, and health literacy competency might be incorporated into the performance evaluation Consider assurance that eligible participation in a tiered reimbursement or other incentive program is structured in a manner that only rewards quality improvement efforts that simultaneously address health disparities Consider developing a provider quality recognition program that could be implemented at different provider levels 26

Lessons Learned 27 Recruit broad representation of stakeholders to ensure diversity of thoughts, views, and expertise State-wide diverse outreach and representation Offer technical assistance in areas of expertise and need Provides technical assistance and presentations on the Community Health Worker model and health disparities data Establish and serve as a point of contact available for research and presentations Serves as a resource to Lt. Governor, Chief of Staff Identify community based organizations and groups who express interest in policy and legislation Provide technical assistance and expertise Distribute draft material widely for input Reaches broader groups

Today, Tomorrow, and Beyond 28 Collaborative Workgroups Provide assistance to the MHQCC Cultural Competency Workgroup Review of draft materials Providing content specific expertise Provide technical assistance and training to HEZ Awardees Continue to inform policy development and implementation Continue to provide technical assistance to other entities working to implement provisions in the Act Participate in ongoing evaluation and program re-articulation

Resources and References Maryland Office of Minority Health and Health Disparities Maryland Health Disparities Collaborative Maryland Office of Minority Health and Health Disparities 2012 ANNUAL REPORT AL% pdf Maryland Plan to Eliminate Health Disparities Plan of Action Maryland Chartbook of Minority Health and Minority Health Disparities Data Data%20Chartbook.pdf Health Enterprise Zone in Maryland Maryland Health Improvement and Disparities Reduction Act of 2012 (SB 234) htm 29

MHHD Contact Office of Minority Health and Health Disparities Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 500 Baltimore, Maryland Website: Facebook: Phone: Fax: