1. 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

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

3. 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

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

5. 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.

6. 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

7. Health Disparities Columbus
Mortality – per 100,000
African American Caucasian
All Causes of Death 1,
Heart Disease
Cancer
Stroke
Prostate Cancer
Diabetes
Hypertension/hypertensive renal disease
Homicide
Infant Mortality (deaths per 1,000 live births) 15 7
HIV disease
Death data =
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)

8. 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 =
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)

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

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

11. 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.

12. 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

13. Addressing the problem – Our Efforts …
Office of Minority Health established
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

14. 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

15. 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.

16. 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

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

18. 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.

19. 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

20. 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

21. 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

22. 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

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

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

25. 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

26. 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

27. 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.

28. 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

29. 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

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

31. Thank you
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