1. Assessing Health Equity in Your Patient Population

2. Objectives
Utilize resources within your institution or practice to better identify your particular patient population
Identify resources within your community that
identify health inequities or disparities
provide services to combat health inequities or disparities
Put your knowledge into action
Develop projects or programs to combat health disparities for your patient population
Assessing your patient population using what you have learned from the previous modules

3. Institutional and Practice Resources
Outpatient Practice
Query your EHR patient demographics:
Age
Ethnicity
Zip code
Insurance carrier (commercial, federal, self-pay)
Common diagnoses
Patient intake questionnaires

4. Institutional and Practice Resources
Institutional/Hospital Resources
Demographics
Billing Office
Registrar
Institutional Officer on Diversity and Inclusion

5. Identifying Local Disparities
I know who I am caring for, now where do I find what disparities may be affecting their care?
Local government resources
Health Department Reports
Examples:
Web resources
Community Health Needs Assessment (CHNA)(
Once you know who your providing care to, it is important to discover what particular social determinants of health that may be affecting them
This is a good opportunity for you to brainstorm with your residents/audience to identify local disparities you think are affecting your patient population.

6. Identifying Local Disparities
Your own experience – what are the unmet needs of your patients that adversely impact their health?
Examples:
Access to mental health care.
Resources for substance abuse
Nutritional counseling
Healthy food options
Transportation to appointments
Limited English Proficiency
Limited health literacy

7. Local Resource Identification
Learn what resources are already available within your community to combat health disparities
Nutritional Support
WIC resources and offices
SNAP programs
Local Food banks/closets and free meal programs
Insurance Program Incentives
Gift cards for baby supplies if they attend a certain number of prenatal appointments and/or postpartum visits
Transportation benefits for those without access to a vehicle
Language/Translator Services
Local Charitable Programs
Clothes closets
Free/reduced care seat programs
Mother’s Day out or child care offerings
Parenting/baby care programs
Healthy eating and nutrition programs
Mental Health and Addiction Resources

8. Local Resource Identification
Who can help me learn about this?
Hospital/Institutional Staff
Social Workers
Case Management
Diversity and Inclusion officers
Your own exploration and web searches
Once you have collected this information, it is very helpful to make this an available resource for others in your program/institution for easy reference

9. Put your knowledge into action
This new knowledge will allow you to:
Improve your understanding of the barriers to care that your patients face and the system of resources in place within your community aimed to help improve health equity
Increase referral and utilization to these local resources
Recognize continued gaps in resources and your role in advocating for your patients
Develop new practice patterns, projects, and programs that can improve the health care outcomes for your patients.

10. Projects and Programs
Based upon what you have learned about your patient population what ideas do you have for a helpful initiative, project, or educational program?

11. Example:
Small Group Activity for Resident Training to raise awareness surrounding local health disparities and resources
This scenario is through the eyes of a newly identified pregnant patient with limited resources as she navigates the local healthcare system
Participants identify barriers to care and social determinants that she faces. They will then identify local resources that are available in their community to help combat these potential barriers and disparities.

12. Another Example: A population health approach to stillbirths
This video and the next slide are from the IHI module on the Triple Aim and is a great example how we apply the principles of population health in understanding and improving patient outcomes.

13. Discussion
What were some of the factors affecting stillbirth rates that you heard in the video? Why couldn't obstetricians solve the problem on their own?
Do you think it would be hard to convince staff and patients to participate in multidisciplinary rounds after a stillbirth? Why might people resist this, and how might you address their concerns?
What other health care problems might be improved by addressing factors outside of health care, for example, living conditions?