Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago How Cultural Competency, Language Access, and Health Literacy Are Integrated Into Programs and Interventions Aimed At Reducing Disparities Marshall H. Chin, MD, MPH Richard Parrillo Family Professor Director, RWJF Reducing Health Care Disparities Through Payment and Delivery System Reform University of Chicago

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Disclosures / Funding  AHRQ T32 HS00084, K12 HS023007, U18 HS  The Commonwealth Fund  HRSA  John A. Hartford Foundation  Merck Foundation  NIDDK K24 DK071933, R18 DK A1, P30 DK  Robert Wood Johnson Foundation  National Quality Forum committees  President, Society of General Internal Medicine  CMS Innovation Center – technical assistance

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care Chin MH, et al. JGIM 2012; 27(8):

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap for Reducing Racial and Ethnic Disparities in Care 1) Recognize disparities and commit 2) Implement QI infrastructure and process 3) Make equity an integral part of quality 4) Design intervention(s) 5) Implement, evaluate, and adjust intervention(s) 6) Sustain intervention(s) Chin MH et al. JGIM 2012; 27:

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap for Reducing Racial and Ethnic Disparities in Care #1 Recognize disparities and commit to reducing them Chin MH. Ann Intern Med 2008; 149:

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Examine Your Performance Data Stratified by Race, Ethnicity, Language, and SES  Individual and organizational readiness to change

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Make Sure Your Disparities Training is State of the Art SGIM Goals for Health Disparities Courses  Existence of disparities, etiologies, solutions  Mistrust, subconscious bias, stereotyping  Communication, trust building  Commitment to reduce disparities Smith WR et al. Ann Intern Med 2007; 147:

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Univ. of Chicago Course Self-insight exercises Field trips & Chicago history Group disparities project Reflective essays and discussion Individual patient care (e.g. interpreters) and policy (e.g. Medicare) Advocacy Vela et al. JGIM 2008; Vela et al. JGIM 2010.

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Stratified Data and Cultural Competency Training Alone Do Not Improve Clinical Performance Measures  Disparity data interventions helpful but not sufficient  Knowledge/attitude interventions helpful but not sufficient - Sequist TD et al. Ann Intern Med 2010

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Hillary Clinton, Black Lives Matter, and Movement Advocacy

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Hillary Clinton and Black Lives Matter  “You can get lip service from as many white people you can pack into Yankee Stadium and a million more like it who are going to say: ‘We get it, we get it. We are going to be nicer,’ ” she says. “That’s not enough, at least in my book.” NY Times. Aug. 19, 2015  “I don’t believe you change hearts,” Mrs. Clinton says, summarizing her basic view of social policy movements. “I believe you change laws, you change allocation of resources, you change the way systems operate.”

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 2  Implement basic quality improvement structure and process –Quality culture –Quality improvement team –Goal setting and measuring –Local champion –Leadership support

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 3  Make equity an integral component of quality improvement efforts

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago IOM Model of Quality

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 4  Design intervention(s) –Determine root causes –Consider 6 levels of influence –Review literature –Learn from peers –Consider specific interventions

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 4  Design intervention(s) –Determine root causes  Process mapping  Talk to target population, not just proxies –Minority providers may not be proxies for the target population

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Conceptual Model Provider Patient Financing / Regulation / Accreditation Health Care Organization Person Community Process Outcomes Access Chin MH et al. Med Care Res Rev 2007 Chin MH & Goldmann D. JAMA 2011

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago 6 Levels of Influence: Cultural Competency, Language Access, Health Literacy  Policy: Clinical performance standards – reimburse. Structural measures of culturally competent organization – e.g. interpreters Clinical outcomes Equity index tools to rate organizations Mandated through legislation

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago 6 Levels of Influence  Health Care Organization: Diversity, Inclusion, and Equity initiatives Equity as a true strategic priority Senior leadership Resources and core team to facilitate and help move mountains within organizations

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago 6 Levels of Influence  Microsystem: Integration of language services and interpreters into care team; make easy to access for providers  Provider: Working with interpreters; Cultural competency training; Shared decision making training

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago 6 Levels of Influence  Patient/Family: Patient empowerment; Shared decision making training; Easy access to language services  Community: Community empowerment; community health workers; Social determinants of health

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 4 (Cont.)  Evidence-based strategies –Multifactorial attacking different levers –Culturally tailored QI –Team-based care –Families and non-health partners –Patient navigators –Interactive skills-based training

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 5  Implement, evaluate, and adjust intervention(s)

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Consolidated Framework for Implementation Research  Intervention (relative advantage)  Outer (external incentives)  Inner (culture)  Individuals (beliefs)  Process (plan, execute, evaluate) Damschroder et al. Implement Sci 2009; 4:50.

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Behavior Change Theory  Beliefs and knowledge –Why innovations are good  Social norms –It’s the culture / QI collaboratives  Environmental factors –Incentives  Self-efficacy –Coaching / QI collaboratives

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Motivation  Intrinsic –Professionalism –Do the right thing  Extrinsic –Financial –Other rewards

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 6  Sustain intervention(s) –Institutionalization  Culture, incentives, integrate into daily operations –Societal Business Case  Direct medical costs - $229 billion  Indirect costs - $1 trillion  Healthy national workforce – US Census Bureau –2050 – Hispanic 30%, Black 13%, Asian 8% Laveist TA 2009; US Census Bureau 2008.

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Where’s the Business Case?

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Roadmap Step 6  Sustain intervention(s) –Values – Right thing to do –Business Case – Align policy incentives  Global payments – Accountable care organizations (ACOs), bundled payments  Population health  Pay-for-performance  Link community & health care system - CDC, HHS  Community needs assessment for non-profit hospitals

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago RWJF Reducing Health Care Disparities Through Payment and Delivery System Reform  Program Office at University of Chicago  Delivery system intervention  Payment reform –Pay for performance –Global payment –Shared savings

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Heckler Report 1985

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago CMS (Medicare & Medicaid) Align the Financial Incentives  Require public reporting of stratified disparities data  Strengthen incentives for prevention and primary care –Global payment / shared savings –Update MD RVU payment schedule – cognitive –Encourage intersectoral partnerships  Pay for reducing disparities –Include equity accountability measures in payment programs

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Align the Financial Incentives 2  Align equity measures across public & private payors  Take care of safety net providers –Adequate payment –Calibrate DSH cuts to insurance expansion –Support for quality improvement –Risk adjustment to create level playing field  Conduct payment and delivery demo projects  Have explicit equity lens - payment and QI

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Leadership Matters “Leadership matters. It is our professional responsibility as clinicians, administrators, and policymakers to improve the way we deliver care to diverse patients. We can do better.” Chin MH. NEJM 2014; 317:

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago