Effort addresses social determinants of health for vulnerable populations
By JULIE MINDA
To improve population health and health care outcomes in the communities it serves, St. Louis' Ascension Healthcare is undertaking a systemwide effort to make health care more equitable. The system is addressing social determinants that impact people's health and longevity.
Ascension Healthcare holds out its participation in the Community Care Collaborative in Austin, Texas, as an example of a health equity initiative. Here, under the watch of nurse Peggy Wright, Austin resident Dale Thele steps on a scale at Austin's CommUnityCare David Powell Health Center. Thele receives his care through the collaborative.
Central Health
"Ascension is putting stakes in the ground," when it comes to health care equity, said Dr. Tamarah Duperval-Brownlee, Ascension Healthcare vice president of care excellence. She said all Ascension Healthcare sites will "have national goals around health care equity so that we all have accountability. We are looking at what is measurable, what we can influence in a rapid period of time and what will have the most impact" on people's health.
Patricia Maryland, president and chief executive of the 151-hospital Ascension Healthcare, said through the approach, "by fiscal year 2022, we will make a huge difference in addressing health inequity." For Ascension Healthcare, improving health equity involves addressing the societal inequities that have an impact on vulnerable populations' health.
Going upstream
Maryland said that analyses from the Institute for Clinical Systems Improvement and the National Academies of Sciences, Engineering and Medicine are helping to "set the tone" for Ascension Healthcare's health equity work.
In its October 2014 paper, "Going Beyond Clinic Walls: Solving Complex Problems," the Clinical Systems Improvement institute says about 80 percent of the factors influencing patients' health have to do with social determinants such as the patients' behaviors and socioeconomic conditions. That report says health care providers must collaborate with organizations in their communites to effectively address those social determinants.
Alexian Brothers Housing and Health Alliance is addressing health inequity in the Chicago area with housing and nutrition programs for physically, economically and emotionally vulnerable people recovering from substance abuse. Here, at Bonaventure House, one of the housing program's sober living residences, food services manager Linda Govan, third from left, visits with a volunteer and residents.
And in its January 2017 report "Communities in Action: Pathways to Health Equity," the National Academies says that health outcomes are directly linked to social factors including poverty, inadequate housing, structural racism and discrimination. Only by engaging the community in interventions targeting those factors can organizations help ensure all people get equal opportunity to achieve optimal health.
Ascension Healthcare convened health equity forums in 2015 and 2017 attended by hundreds of its system and facility leaders. The conclaves were used to further understanding of variables driving health inequity and to develop the system's strategies in that arena.
Five prongs
In recent months, the system has formalized its approach to achieving health equity, and Duperval-Brownlee is leading the roll-out of the work throughout Ascension Healthcare.
The five-pronged strategy includes:
- Establishing health equity as a strategic priority for all of Ascension Healthcare's 2,600 care sites, including its hospitals, long-term care facilities and outpatient locations.
- Putting in place structures and processes to ensure that Ascension Healthcare facilities can collect and use patient demographic and socioeconomic data in a standardized way. This includes collection of patient race, ethnicity and language data systemwide.
- Deploying specific strategies including clinical improvement initiatives that address social determinants of health.
- Decreasing the implicit bias that staff may have when delivering care. This can include misunderstandings that may arise when patient and caregiver do not speak the same language, or have different ethnicities or belief systems.
- Partnering with community organizations to improve health and health equity.
Cardiac care, cancer care
Ascension Healthcare has overlaid the health equity rubric on two preexisting clinical initiatives. The system plans to use an "integrated scorecard" systemwide to gauge how well it is addressing disparities in heart failure readmissions and colorectal cancer screenings.
Duperval-Brownlee
Duperval-Brownlee said studies have shown that there is a disparity in the readmission rates after heart failure treatment when poor and isolated people are compared to heart failure patients who are neither impoverished nor isolated.
For about five years, all Ascension Healthcare sites have been working to improve the health outcomes of vulnerable low-income heart failure patients, including those insured by Medicaid. This involves individualized follow-up with these patients after hospital discharge to connect them with resources that address socioeconomic barriers that may make it harder to comply with doctors' instructions and manage chronic heart disease. Care navigators help coordinate the patients' post-acute care across multiple specialties and providers.
Ascension Healthcare facilities have increased colorectal cancer screening rates for low-income patients, including those insured by Medicaid. The system partners with churches and other community organizations to build awareness of the value of the screenings. Ascension Healthcare has a systemwide goal to achieve a 13 percent reduction in patients not current with their screenings by fiscal year 2019. The goal is a 15 percent reduction for Medicaid patients.
Duperval-Brownlee said Ascension Healthcare will add other scorecard goals beyond these two in the future.
Community partnerships
In addition to those systemwide initiatives, Ascension Healthcare is encouraging its hospitals to collaborate with community partners to address health inequities surfaced in community health needs assessments.
Ascension highlighted for Catholic Health World three examples of effective collaboration:
- A program of Arlington Heights, Ill.-based AMITA Health relies on a collaboration with the Illinois housing department to provide transitional housing and multidisciplinary health care services to people with HIV, AIDS or other chronic illnesses. AMITA's Alexian Brothers Housing and Health Alliance provides the housing and local health care organizations provide the care. Duperval-Brownlee said the program has reduced hospital admissions for clients and enabled them to stabilize their lives. Many who had been unemployed secured jobs and were able to move into permanent housing.
- A food backpack partnership between the 16 hospitals of St. Vincent Indiana in Indianapolis and schools in their communities feeds children who might otherwise go hungry on the weekends, when they are unable to access schools' free lunch programs.
- A collaboration between the Austin, Texas-based Seton Healthcare Family, the Travis County health care district and other providers helps ensure that an estimated 95,000 uninsured and underinsured residents have access to primary and specialty care. Members of the Community Care Collaborative are making inroads in improving care efficiencies and patient outcomes, said Geronimo Rodriguez, the Texas division chief advocacy officer for Ascension Healthcare.
Rodriguez said the collaborative model used in Travis County and in similar efforts at other Ascension Healthcare sites to address health inequity has allowed for shared accountability and a smoother path to more holistic care for community members.
He said of the Travis County efforts "as I watch our team do this work — I'm amazed at how our mission always rises to the top. As Catholic health care providers, we believe every individual is endowed with dignity, and we want to ensure those words align with our actions.
"That is why we are doing this work," he said.
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Ascension Healthcare improves data collection to support health equity work
A key component of Ascension Healthcare's health equity initiative is enhancing how it collects and uses patient data. The system is standardizing the types of data it gathers and the systems it inputs the information into. It is training associates to ask potentially delicate questions in a straightforward, nonjudgmental way.
Dr. Tamarah Duperval-Brownlee, Ascension Healthcare vice president of care excellence, said completing this data infrastructure work is "a herculean challenge," with about 2,600 care sites, 151 of them hospitals.
The goal is to collect demographic and socioeconomic information from every patient in a standardized way and to ensure associates have a protocol for acting upon the information gathered, in an effective way.
The system has been rolling out a common data platform across all its legacy electronic medical record platforms, so that staff involved with patient data intake ask the same questions, irrespective of the inpatient or outpatient setting.
Demographic questions have to do with personal characteristics such as race, ethnicity and gender. Socioeconomic questions cover such aspects as patients' ability to access medication and food; their employment status, transportation and housing security; their personal safety from violence; their ability to afford child care if they need it — and many more categories in this vein.
In training employees, Ascension Healthcare is emphasizing to them the mission reason for the approach, which is in part to provide "spiritually-centered, holistic care which sustains and improves the health of individuals and communities."
Ascension Healthcare also has been developing protocols and guidelines for all employees who will be working with the new patient data collection system. This includes anticipating sensitivities around gathering demographic data. For instance, employees will learn how best to ask about the gender identity of patients who are transitioning from one gender to another. Duperval-Brownlee said the system wants to respond to each patient "in an equitable and compassionate way. We want to welcome all."
Ascension Healthcare is helping employees think intentionally about their role in helping patients to address surfaced needs proactively, to work with navigators and community partners to resolve issues and to head off personal crises that can worsen health problems. Employees will aim to build trusting relationships with patients along the way.
"This allows for everyone on the health care team to be empowered" to address health inequity, said Duperval-Brownlee.
— JULIE MINDA
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