Integrated framework for reducing racial and ethnic disparities in the quality of health care
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Integrated Framework for Reducing Racial and Ethnic Disparities in the Quality of Health Care. Marshall H. Chin, MD, MPH, and Don Goldmann, MD University of Chicago, Institute for Healthcare Improvement. Roadmap.

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Integrated framework for reducing racial and ethnic disparities in the quality of health care

Integrated Framework for Reducing Racial and Ethnic Disparities in the Quality of Health Care

Marshall H. Chin, MD, MPH, and Don Goldmann, MD

University of Chicago, Institute for Healthcare Improvement


Roadmap

Roadmap

Context and problems in current efforts to reduce disparities in health care quality

Conceptual models for reducing disparities

Evidence on disparity interventions

6 key components for reducing disparities

Implications for funders

Exercise: Advice to AHRQ


Promising time

Promising Time

  • Increased public awareness of disparities

  • Health reform legislation will increase collection of race, ethnicity, and language data

  • Increased motivation for providers and health care organizations to address disparities

  • An opportunity to move from description and complaint to action


Problems and gaps

Problems and Gaps

  • Lots of research on the magnitude of disparities, but relatively little work on interventions to reduce disparities

  • Many providers, organizations, and policy makers do not know where to start to reduce disparities

  • Despite language encouraging proposals on vulnerable populations, many public and private funders receive few applications


Models models models

Models, Models, Models

  • Models can inform approaches to disparities, but….

  • Models must be customized to address the unique underlying causes of disparities directly, but….

  • Customized solutions are sparse, therefore….

  • The nation’s research agenda must be directed at testing interventions that address disparities specifically


Level of engagement model

Level of Engagement Model

  • Patient/Person

  • Provider

  • Microsystem - small unit of care delivery

  • Organizations that house or support microsystems

  • Communities and regions that span care delivery, prevention, and health promotion for populations

  • Environment of policy, payment, regulation, accreditation

Based on Berwick, Health Affairs 2002;21:n. 3


Planned care conceptual model

Planned Care Conceptual Model

Community

Health System

Resources and Policies

Organization of Health Care

Self-Management Support

ClinicalInformationSystems

DeliverySystem

Design

Decision

Support

Informed,

Activated

Patient

Prepared,

Proactive

Practice Team

Productive

Interactions

Functional and Clinical Outcomes

Wagner


New iom framework

New IOM Framework


Rwjf finding answers conceptual model chin et al med care res rev 2007 64 7s 28s

RWJF Finding AnswersConceptual ModelChin et al. Med Care Res Rev 2007; 64:7S-28S

Policy / Payment / Regulation / Accreditation

Health Care

Organization

Community

Provider

Access

Person

Patient

Process

Outcomes


Systematic reviews

Systematic Reviews

Reviewed 200+ articles

Condition-specific

Cardiovascular disease

Diabetes

Depression

Breast cancer

Cross-cutting

Cultural leverage

Pay-for-performance incentives

FAIR Database


Common successful interventions from systematic reviews

Common Successful Interventions from Systematic Reviews

Multifactorial interventions that address multiple leverage points along a patient’s pathway of care

Culturally tailored QI more than generic QI

Nurse-led interventions with multidisciplinary teams and close tracking and monitoring of patients

Chin MH, et al. Med Care Res Rev 2007; 64:7S-28S.


Review of pediatric literature asthma immunizations

Review of Pediatric Literature (Asthma, Immunizations)

  • Measure and improve structural aspects of care experience that impact outcomes

  • Incorporate families into interventions

  • Integrate non-health care partners into QI interventions

Chin MH, et al. Pediatrics 2009;124 (Suppl 3):S224-S236.


Lessons from rwjf finding answers disparities research for change grantees

Lessons from RWJF Finding Answers: Disparities Research for Change Grantees

  • Knowledge/attitude interventions helpful but not sufficient

  • Providing disparity data helpful but not sufficient

  • Context and tailoring are critical

  • Multifactorial, multitarget interventions

  • Intervention & the process of implementation

  • Buy-in, incentives, sustainability, system


Integral components of systems approach to reducing disparities

Integral Components of Systems Approach to Reducing Disparities

1) Examine your performance data stratified by insurance status, race/ethnicity, language, and socioeconomic status.

  • Get training for your staff to work effectively with diverse populations.

  • Make reduction of inequities in care for vulnerable populations an integral component of quality improvement efforts.

Chin MH. Ann Intern Med 2008; 149:206-208.


Systems approach 2

Systems Approach - 2

Provide models of care and infrastructural support to enable organizations to improve the quality of care for vulnerable patients.

Align incentives to reward providers and health care organizations for providing high quality care to vulnerable populations.

Allocate more resources for the uninsured with chronic diseases.


Implications for funders

Implications for Funders

  • Move beyond asking applicants simply to show that they have included “priority populations” in their research plan

  • Ask all quality of care applicants to address specifically how they will reduce known disparities or gaps discovered in the course of the work

    • Include a measurement plan that stratifies data appropriately

  • Design an overall portfolio of grants and grantees that addresses improving outcomes and reducing gaps in diverse populations and settings

  • Reward applicants who address equity issues


Spheres of influence for disparity interventions

Spheres of Influence for Disparity Interventions

  • Patient/person

  • Provider

  • Microsystem

  • Health care delivery organization

  • Community and region

  • Policy, payment, regulation, accreditation

Which spheres are you addressing or plan

to address in your comprehensive,

multifactorial approach to reducing an equity gap ?


Example care coordination for chronically ill patients

Example - Care Coordination for Chronically Ill Patients

  • Patient: engagement, empowerment, mobilization

  • Provider: engagement, training in health literacy and cultural competency

  • Microsystem: teamwork, communication, QI, practice redesign, stratified data and real time feedback


Care coordination for chronically ill patients 2

Care Coordination for Chronically Ill Patients - 2

  • Health care delivery organization: communication, coordination, support for patients and families across the continuum, tele-health and monitoring, focus on value and longer term fiscal horizon

  • Community: activation, mobilization of non-medical resources and supports, attention to social capital and environment

  • Policy – alignment of incentives and payment to promote the above actions


Exercise advice to ahrq

Exercise: Advice to AHRQ

  • Request For Applications

    • Think of your research area

    • Pick one of the 6 spheres of influence

    • Write a research question you’d like to be a priority area for the RFA for your research area in that sphere of influence

    • If time, write questions for other spheres

  • To reduce disparities in health care quality, what else might AHRQ do, in addition to directing and supporting research on specific topics?


Spheres of influence for disparity interventions1

Spheres of Influence for Disparity Interventions

Patient/person

Provider

Microsystem

Health care delivery organization

Community and region

Policy, payment, regulation, accreditation


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