"Since God chose you to be the holy people he loves, you must clothe yourselves with tenderhearted mercy, kindness, humility, gentleness and patience." — COLOSSIANS 3:12
BY: MARCOS L. PESQUERA, RPh, MPH
I began my career as a community pharmacist, with all the optimism and idealism that belong to the young. In the flurry of filling prescriptions in a busy pharmacy, occasionally I would notice a patient who only wanted to purchase two- or three-days' worth of medication for their chronic condition. Obviously, I was concerned. A chronic condition such as hypertension (high blood pressure) requires that medication be taken regularly as prescribed to avoid serious consequences. Certainly, the patient had been educated about that. I found my attitude more critical than compassionate in those circumstances.
I know now that I was oblivious to the realities of some people's lives and ignorant of the socio-economic challenges that may have been factors in their decision making. Thankfully, through experience and my own continuing education, I have grown to understand more about the reasons why patients may not be able to carry through with the medical advice from their health care providers. The importance of understanding our patients' social realities was clearly highlighted again for me recently. On February 20, I had an opportunity to volunteer with a group of CHRISTUS employees at a phone bank, answering community concerns about the new "public charge" rule. (The federal rule makes it hard for legal immigrants to gain permanent residency if they have Medicaid coverage for 12 months within a three-year period, or federal nutrition or public housing benefits.) I was astonished and disappointed with how many calls we received from people in the community who were extremely confused about the rule, and how misinformation they'd heard prompted many to even disenroll their children from the CHIP program and other services.
Understanding people's social realities is critical to our ability to provide care that is culturally competent and relevant to the patients we serve. For health care systems that strive to extend the healing ministry of Jesus Christ, this understanding brings compassion. Compassion is central to preserving the dignity of all people under our care.
Many barriers and much history contribute to how people in vulnerable communities experience their health. This experience extends beyond their health care. What are the socioeconomic factors and other realities that affect people's physical, mental and spiritual health? Do you want to understand someone else's perspective? Strive to comprehend what it may be like to walk in their shoes, ask questions, interview others and approach every conversation with humility and an attitude of seeking understanding.
The following are only a few of the strategies we employ within the CHRISTUS Equity of Care pilot program. As research has shown, racial and ethnic minorities experience poor health outcomes when compared to their white counterparts. These differences in outcomes can be attributed not only to treatment within the health care environment but also as a result of social, political and environmental barriers. At CHRISTUS, we are intentional about promoting a culture of inclusion. We have a team dedicated to identifying areas of health inequities; the team creates solutions to mitigate barriers to optimal health outcomes. In early 2018, this team identified hypertensive patients who utilize our emergency department for their primary care. The Equity of Care pilot began in March of 2018 in our Santa Rosa ministry in Texas. We soon expanded the program to all our ministries within the U.S. The pilot program integrated questions and data about social determinants of health — conditions that affect a wide range of health risks and outcomes — into health assessments and clinical processes throughout the CHRISTUS Health system, from ambulatory settings to in-patient care.
- CHRISTUS is committed to understanding our patients' health challenges as well as social barriers that prevent them from experiencing health and well-being. By looking at utilization patterns of patients who are uninsured or underinsured, we identified a target cohort of people with hypertension, a chronic condition. The majority of patients in this cohort are from ethnic minorities who, due to lack of access and a distrust of the health care system, come to us for care only when they are in a health crisis and are usually entering through our emergency rooms.
- Each patient within the group is paired with a care navigator, who conducts a social assessment. This questionnaire assists the navigator in identifying social barriers that keep the patient from managing their condition and factors that may be preventing them from following treatment recommendations.
- The navigator arranges for the patient to connect with social agencies that can support them in their particular challenges, such as food insecurity, assistance in making appointments with primary care medical homes, transportation resources and prescription assistance. (See graph above.)
Results show that doing the right thing produces the right outcomes. In addition to the many referrals that help our patients move beyond social and economic barriers and extend a safety net, more appropriate use of services for specific conditions is taking place. Even at a cursory review, revisits at the emergency department show a downward trend for a primary diagnosis of hypertension. As seen in the chart, a six-month review of targeted patients shows a decline in using the emergency department to treat their hypertension from 12% to 10%, and subsequent data is showing continued improvement. Ongoing analysis is underway, but indicator trends are pointing to positive signs that the Equity of Care program is educating and empowering our patients to be more active participants in improving their health and changing the trajectory of their health outcomes. With the onset of the pandemic, we have been able to redirect some of the Equity of Care resources to monitor our uninsured COVID-19
patients who are quarantined at home.
- CHRISTUS Health understands that a diverse and inclusive organization results in better performance. The health care industry has wrestled for years with leadership diversity in executive roles and C-suites. At CHRISTUS Health, we are committed to change that. Why? Because when our patients look at us, they want to see themselves. Multiple perspectives and life experiences bring real solutions to the table, and our biases are so embedded into our collective psyches that we need to be intentional about our efforts. The principles of inclusion lead us to specific inquiries and actions, from asking community councils to bring us feedback, surveying our staff for job satisfaction, to asking our patients about their experience with us. This is all carried out in a quest to demonstrate the healing ministry.
- We utilize a survey of our associates' experience to create a Diversity & Inclusion Index. This D&I Index is made up of five parameters: Authenticity, Belonging, Inclusion, Recognition and Respect. Leaders who score below the health care average are given the opportunity to attend an Essence of Respect training or one-on-one coaching that focuses on practicing inclusive behaviors and learning how to model them.
Last year, 40% of our executive hires were minority. In our Latin American ministries, over 50% of executive hires were women. This year we are intentional about increasing the number of minorities we hire and closing the gap. We are steadfast about these efforts because we are committed to providing care that is relevant and culturally appropriate to the communities and populations we serve.
The stories of new hope, improved health outcomes and experiencing God's healing presence are many. Here is one:
Through our Equity of Care Program, we reached out to a 47-year-old African American man from Louisiana. He is a commercial truck driver but has no insurance or primary care provider. He has been to the emergency department numerous times for high blood pressure. At the time we engaged with him, he was overweight, smoked 2-3 packs of cigarettes a day and, as is often the case for drivers on a tight schedule, most of his diet came from fast food restaurants. He kept himself going with a steady supply of energy drinks and coffee.
The man was very skeptical when contacted by our care manager, Susan Jewett. She expressed concern for his health and his ability to pass the driver's test from the department of transportation due to his poor health. Susan listened to the man and used a technique called motivational interviewing, which is a collaborative counseling style designed to enhance a person's internal motivation to health behavior change. He expressed his vision of where he wanted to be in five years and verbalized his understanding of the importance of improving his health for his own future and for his children. The nurse proceeded to connect him with a Federally Qualified Health Center, or FQHC, for primary care, prescription assistance and healthy lifestyle education.
When Susan called two weeks later, he already had made an appointment with a primary care provider and expressed how determined he was to change. He was no longer consuming energy drinks, had started walking regularly and had decreased his smoking. His blood pressure numbers were lower.
At the two-month call, "patient had visit with FQHC, medication for blood pressure was adjusted and he was down to 1 pack a day and was losing weight."
"Pt. feels like he is taking control of his life for himself and family. Pt. is no longer worried about passing Department of Transportation physical exam."
At the six-month outreach call, "patient's blood pressure was excellent, had quit smoking, lost 40 pounds, exercises daily and his life had turned around."This is a quote from this patient: "Your caring made a difference. It is just not the assistance finding a doctor or education; it was the support and encouragement you have given me from the heart. You are an angel, you genuinely care and it shows with your love."
It is through the hands of all our associates working together that we are able to see our mission in action, to extend the healing ministry of Jesus Christ. As noted in the First Epistle of John: "Little children, let us love, not in word or speech, but in truth and action."
MARCOS L. PESQUERA is the system vice president for community benefit, health equity, diversity and inclusion at CHRISTUS Health, based in Irving, Texas.