Achieving Health: Disparities, Access and Equity Complexities in Michigan and Beyond

1. Achieving Health: Disparities, Access and Equity Complexities in Michigan and Beyond Ramona Benkert, PhD, ANP-BC, FAANP Wayne State University ramonabenkert@wayne.edu

2. Objectives • Describe the various terms associated with access and equity in health care. • Summarize the current research and data on social determinants of health. • Understand the role that nurses play in enhancing access and equity in healthcare • Discuss evidence-based recommendations for nurses and nursing practice at the Patient, Practice and Community Level.

3. Socioecological Model of Health

4. What is Health? • According to the World Health Organization: “Health is the state of complete, physical, mental and social well-being and not merely the absence of disease or infirmity.”

6. Health Disparities

7. Health Inequities Defined • Health inequities, as described by Margaret Whitehead*, are "differences in population health status and mortality rates that are systemic, patterned, unfair, unjust, and actionable, as opposed to random or caused by those who become ill." *Margaret Whitehead (Head of the WHO Collaborating Center for Policy Research on the Social Determinants of Health - + Health Outcomes Advantages Disadvantages

8. “Access to Care” is a Health Care Inequity • Access to a provider (medical, dental, mental health) • Access to medications

9. Access to Care is Not simply… having a coverage and services for care • Access to health care consists of four components (Healthy People 2020): • Coverage: facilitates entry into the health care system. • Services: Having a usual source of care • Timeliness: ability to provide health care when the need is recognized. • Workforce: capable, qualified, patient centered, and culturally competent providers.

11. Social Determinants of HealthInfluences over50% of our Health

12. VS.

13. Robert Wood Johnson County Health Rankings

14. Population Level Disparities in Michigan Infant Mortality-Best Counties (2013-17) Lowest #/1000 live births Michigan 6.8 Infant Mortality-Worst Counties (2013-17) Larget #/1000 live births Michigan 6.8 Presque Isle 12.4 Crawford 11.4 Wayne 9.5 Genesee 8.7 Kalkaska 8.1 • Chippewa 3.5 • Midland 4.2 • Livingston 4.4 • Alpena 4.4 • Delta 4.4

15. Population Level Disparities in Michigan Cancer Mortality 2017 Largest #s/100,000 Michigan Average 207 Cancer Mortality 2017 Lowest #s/100,000 Michigan Average 207 Washtenaw 137.1 Luce 141.6 Kent 146.5 Kalamazoo 151.3 • Roscommon 443.6 • Alcona 425.1 • Schoolcraft 385.1 • Presque Isle 375.3 • Oscoda 362

16. Comparisons SDOH Inequities in Counties with Differing Infant Mortality Data Presque Isle Statistics Chippewa Statistics The median income for a family was $54,625. About 2.3% of families were below the poverty line. 17% uninsured 76% high school graduation Good health care access 9.4% unemployment • The median income for a family was $37,426. • About 6.80% of families were below the poverty line. • 17% uninsured • Unknown high school graduation • Health shortage area • 12.7% unemployment

17. Comparisons SDOH Inequities in Counties with Differing Cancer Data Roscommon Statistics Washtenaw Statistics The median income for a family was $51,990 14% children below the poverty line. 10% uninsured 84% high school graduation Good health care access 4.8% unemployment • The median income for a family was $33,929 • 34% children below the poverty line. • 16% uninsured • 73% high school graduation • Health shortage area • 11.3% unemployment

18. Race For ResultsU.S. data

19. Health Professional Shortage Areas (HPSAs) & Medically Underserved Areas (MUAs) • HPSAs and MUA/Ps are areas, population groups, and facilities designated by the United States Department of Health and Human Services • The scores imply access to a “usual source of care”. • Each county or area is scored from 1 to 17 or higher on need. • Higher number means greater need

20. Michigan Primary CareHPSAs

21. Michigan Mental Health HPSAs

22. What Can We do as Nurses?Taking Action

24. Traditional Model of Health Care: Necessary but Insufficient

25. Taking Action • Patient Individual Level • Practice/Unit/Institutional Level • Community Level

26. Patient Level: CLEAR Collaborative • Community Links Evidence to Action Research Collaboration • Treat/Ask • Refer • Advocate • CLEAR toolkit, Available in 10 languages

27. Patient Level: Treat and Ask • Asking about SODH in a sensitive and caring manner • Creating safe spaces for disclosure of SDOHs • Enhance your own “cultural” competence: • gender, race/ethnicity, abilities, literacy- • Evaluate one’s own unconscious implicit bias

28. Patient Level: Screening Tools • Do you ever have difficulty making ends meet at the end of the month? • Do household member have stable work with safe working conditions? • Who cares for your children while household members are working? • Is there enough to eat at home? • Do you and your family have a safe and clean place to sleep? • Do you feel safe at home? • Do you have friends or family to depend on in times of need?

29. Patient Level: EHRs, Diagnosing and Prescribing • Chart reminder and recall systems to flag patients at risk can be useful in triggering more holistic care. • Social Diagnoses need Social Prescribing • A: Difficulty accessing medicine due to limited insurance • P: Refer to social worker, Social work consult, Link to Patient Navigator, #s

30. Patient Level: Advocate for Patients • Referring patients and helping them access benefits and support services- • Writing letters • Maintain an up to date list of community resources (work with social work department) • Build upon the patient’s strengths and resilience

31. Practice Site/Unit/Institutional Level: Support Organizational Efforts • Support your employer’s efforts to identify disparities through data and eliminate them through proactive quality initiatives. • Key Organizational level strategies: • Inequity responsive care • Trauma informed are • Contextually tailored care • Culturally competence care • Senior Management Support is CRUICIAL

32. Practice Site/Unit/Institutional Level: PCC

33. Practice Site/Unit/Institutional Level:Equity of Care National Collaborative • Call to action to eliminate health care disparities. • American Hospital Association, and others of the United States. • The goals are to: • increase the collection and use of race, ethnicity and language preference data; • increase cultural competency training; and • increase diversity in governance and leadership

34. Practice Site/Unit/Institutional LevelWhere to Start?? • Review the Equity of Care Toolkit • Find out where your organization stands in progressing toward the three goals of the call to action. • Compare your results to the 2013 Institute for Diversity in Health Management’s Diversity and Disparities survey results. • Encourage colleagues in the field to join this effort by sharing your journey with them

35. Practice Site/Unit/Institutional LevelUse of the Equity Tool Kit • Engage in quality improvement by: • Selecting a quality measure to stratify by race, ethnicity and language preference. • Creating a plan to ensure your staff receives cultural competency training. • Have a dialogue with your board and/or leadership team on • How do you reflect the community you serve? • What actions can be taken to address any gaps?

36. Practice Site/Unit/Institutional LevelEnhance Access Beyond Finding a Site for care—Change the site • Improving access and quality of care for hard-to-reach patient groups • Reduce barriers: bus tickets, interpreter services, child care • Patient support navigators on the care team • Altering the schedule or time with patients • Ongoing support for providers

37. Community Level: Michigan Health Equity Roadmap Recommendation 3: Improve social determinants of racial/ethnic health inequities through public education and evidence-based community intervention Recommendation 4: Ensure equitable access to quality healthcare. Michigan Health Equity Roadmap, MDHHS

38. Community Level: Learn and Engage • Learn about your community • Partner with community groups and local leaders • Use evidence to support for social change • Getting involved in community needs assessment and health planning

39. Community Level:Bronson Community Health Survey • Bronson serves Southwest Michigan: Kalamazoo, Allegan, Barry, Eaton, VanBuren, Calhoun, Berrien, Cass, St. Joseph, and Branch Counties. • The Michigan Coalition Against Homelessness average daily census report showed Kalamazoo with the highest census of 436, followed by Calhoun 143 and Van Buren 23. • 30% of Calhoun and Van Buren County households earn less than $25,000 per year

40. Community Level:Bronson Community Health Survey • Percent of people in poverty ranged was highest in Van Buren County (21%) followed by Calhoun (19%) and Kalamazoo (18%). • Van Buren County has the highest overall percentage of children in poverty (31%), followed by Calhoun (26%), and Kalamazoo (21%). • In all regions, the proportion of Blacks living in poverty is higher than Whites

41. Community Level:Evidence Based Strategies-Access to Care • Access to care: • Centering Pregnancy • Community Health Workers • Federally Qualified Health Centers • Primary Care Medical Homes • Rural Health Training • Diversify the Professions

42. Community Level:Evidence Based Strategies-Health Inequities • Health Equity • Support adult vocational training • Encourage GED certification • Support Paid Family Leave programs

43. Community Level:Achieving Patient Centered Care • Understand your community of interest • Establish Trust : Decrease Mistrust • Determine what matters to Patients and then… • Evaluate the system of care

45. References • Agency for Healthcare Research and Quality. National Healthcare Quality and Disparities Reports. Accessed athttps://www.ahrq.gov/research/findings/nhqrdr/index.html • Abraham M, Moretz JG. Implementing patient- and family-centered care: part I – understanding the challenges. PediatrNurs. 2012;38(1):44-7. • American Hospital Association. Equity of Care: A Toolkit for Eliminating Health Care Disparities Accessed at: http://www.diversityconnection.org/diversityconnection/membership/Resource%20Center%20Docs/equity-of-care-toolkit.pdf • Andermann. A. Screening for social determinants of health in clinical care: moving from the margins to the mainstream Public Health Reviews (2018) 39:19, https://doi.org/10.1186/s40985-018-0094-7 • Andermann, A. Taking Action on the social determinants of heath in clinical practice: a framework for health professionals. CMAJ, December 6, 2016, 188(17–18) • Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-1.

46. References • Bechtold, A. & Fredericks, S. (2014) Key concepts in patient-centered care. July 2014 Vol. 9 No. 7. • Berwick DM. What “patient-centered” should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-65. • Bronson Hospital Community Assessment. Accessed at: https://www.bronsonhealth.com/app/files/public/2302/BMH-Community-Health-Needs-Assessment-Report.pdf • CLEAR Collaborative toolkit. Accessed at: https://www.mcgill.ca/clear/ • Ford PE, Rolfe S, Kirkpatrick H. A journey to patient-centered care in Ontario, Canada: implementation of a best-practice guideline. Clin Nur Spec. 2011;25(4):198-206. • Harvard University. Project Implicit. Accessed at: https://implicit.harvard.edu/implicit/takeatest.html • Healthy People 2020. Accessed at: https://www.healthypeople.gov/ • Hobbs JL. A dimensional analysis of patient-centered care. Nurs Res. 2009;58(1):52-62.

47. References • HRSA Cultural Language and Health Literacy. Accessed at: https://www.hrsa.gov/cultural-competence/index.html • Iezzoni LI, Barreto EA, Wint AJ, et al. Development and preliminary testing of the health in community survey. J Health Care Poor Underserved 2015;26:134-53. • Kirwan Institute of rhteStudy of Race and Ethnicity. Implicit Bias Training. Accessed at: http://kirwaninstitute.osu.edu/implicit-bias-training/ • Michigan Department of Health and Human Services Health Equity Learning Modules. Accessed at: https://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955-174390--,00.html • Michigan Primary Care Association. Accessed at: https://www.mpca.net/ • Michign Health Equity Roadmap. Accessed at: https://www.michigan.gov/documents/mdch/MI_Roadmap_FINAL_080310_revised_WEB_VERSION_329422_7.pdf

48. References • New England Journal of Medicine (Online). What Is Patient-Centered Care? Accessed at: https://catalyst.nejm.org/what-is-patient-centered-care/ • Robert Wood Johnson-County Health Rankings. Accessed at: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies?f%5B0%5D=field_program_health_factors%3A12068 • Rickert, J. (January 24, 2012 2012). Patient-Centered Care: What It Means And How To Get There. Health Affairs: 10.1377/hblog20120124.016506 • Sampson, H. et al Reducing Health Inequities in the United States: Insights and Recommendations from the National Heart, Lung, and Blood Institute’s Health Inequities Think Tank Meeting. J Am Coll Cardiol. 2016 Aug 2; 68(5): 517–524. doi: 10.1016/j.jacc.2016.04.059