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2 Improving Care for Socially At-Risk Populations
Pages 17-68

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From page 17...
... . Although these populations receive care from a wide range of providers, they are disproportionately represented among the patients treated by a small subset of providers, including safety-net hospitals, minority-serving institutions, critical access hospitals, and community health centers (CHCs)
From page 18...
... . Compared to both non–critical access hospitals generally and to urban acute care hospitals specifically, critical access hospitals provide lower-quality care on average and have higher mortality rates for AMI, heart failure, and pneumonia (Joynt and Jha, 2011; Joynt et al., 2013; Lutfiyya et al., 2007)
From page 19...
... Safety-net primary care providers include community health centers and minority-serving providers. CHCs, also known as federally qualified health centers, and federally funded health centers provide primary care and preventive services to socially at-risk populations such as Medicaid patients, uninsured patients, migrants, and the homeless.
From page 20...
... PRACTICES TO IMPROVE CARE FOR SOCIALLY AT-RISK POPULATIONS The mechanisms underlying disparities in health care outcomes are complex and include both specific practices that occur during the provider–patient encounter and systemic differences that occur between treatment settings (Hasnain-Wynia et al., 2007, 2010)
From page 21...
... The committee reviewed both the peer-reviewed and grey literature in order to identify innovations, interventions, and other strategies providers disproportionately serving socially at-risk populations have implemented to improve care and outcomes for their patients. As described in Chapter 1, the committee reached out to organizations known to conduct research or represent providers disproportionately serving socially at-risk populations (Alliance of Community Health Plans, America's Essential Hospitals, America's Health Insurance Plans, and The Commonwealth Fund)
From page 22...
... Note that "system" as used here is not limited to a single health care organization, but refers more generally to a set of interconnected actors who work together to accomplish a common purpose -- in this case to improve health equity and outcomes for socially at-risk populations. In this approach, the system is mainly composed of medical providers as well as partnering social service agencies, public health agencies, community organizations, and the community in which those medical providers are embedded.
From page 23...
... It is important to note that these practices together constitute a general approach to identifying and developing best practices for a specific community context and given specific resources. Unlike clinical best practices that are applied to all individuals in a given population and that are derived from systematic reviews of the evidence to identify causal associations, these systems practices are not interventions that can be applied wholesale in every practice setting for every patient and in every community context and be expected to improve quality and outcomes for socially at-risk populations.
From page 24...
... (Colema et al., 200 an 06; Davis et al., 2005; Naylor et al., 2004; Wagn et al., 199 these ar typically li 2 ner 96) , re imited to cli inical teams, whereas this model also in w m ncorporates collaborativ partnership with exte ve ps ernal organizattions, includ ding not only other clinic care prov y cal viders, but al communi organizat lso ity tions and socia service and public hea agencies to address s al alth s social risk fa actors.
From page 25...
... As such, they are not a representative sample of strategies used by providers and are inherently interventions tailored to meet the needs of specific populations in specific community contexts. Additionally, particular strategies and their affect on improving health care quality and health outcomes may not be replicable by different providers and in different settings.
From page 26...
... Health care • Integration health equity into strategic planning, including value in a health system requires providers accept quality improvement processesc: leadership and a change in accountability for o Internal leaders designated responsibility for developing and organizational culture. Leadership reducing inequities.
From page 27...
... k Chin, 2016; Chin et al., 2012; Curry et al., 2011; Davis et al., 2015; IOM, 2003; Jones et al., 2010; Taylor et al., 2015. TABLE 2-1b Description of Systems Practices to Improve Care for Socially At-Risk Populations and Implementation Considerations: Data and Measurement Systems Practice Description Example Implementation Strategies Implementation Considerations Data and Health care providers • Regular, standardized collection of social risk factor dataa The concentration of socially at measurement: understand their patterns • Analysis and monitoring of performance data risk patients among a small subset Understand your of performance across disaggregated by indicators of social risk to identify of health care providers means population's different indicators of existing health disparities within organizationsb that many providers will be unable health, risk social risk.
From page 28...
... peers to identify lessons • Data sharing with other providers, public health and and anticipate their patient social service agencies, and community organizations to population's needs. Based identify patients' social needsb on these activities, o Information exchange portal for clinical providers, providers design programs social service agencies, public health agencies, and and practices that community organizations to share information (with anticipate and respond to patient permission)
From page 29...
... Collaborations • Regional collaborations with other health care providersd become clearer. In addition, must be sufficiently • Involvement and collaboration with social service and effective models of collaboration integrated to share public health agencies and community organizationse will differ based on the specific information and critical patient needs and community insights about patients.
From page 30...
... to coordinate care between clinical and to monitor patients to ensure that clinical and social clinical care, between social service providersc progress is maintained, as well as needs clinical care teams, • Collocating clinical, behavioral health, and social to detect relapse and re-intensify between health care servicesd services as needed. providers and social • Patient education about care transitionse service agencies and community organizations, and differing intensity of needed services.
From page 31...
... to promote healthy behaviors and reduce health different forms (e.g., nurse risksd care manager or • Reach patients through community centers, homeless community health worker) shelters, religious organizations, schools depending on the level of severity and desired site of care (office visits versus phone consultation versus home visits)
From page 32...
... Health care organizations may also intervene directly on social issues -- for example, providing supportive housing or opportunities for socialization. Finally, health care organizations may identify social risk factors that the medical or clinical health system cannot address or should not address.
From page 33...
... Kaiser Permanente is a large, nonprofit integrated managed care organization that provides a case study of a community-informed health system. Kaiser's comprehensive, multifaceted approach to improving community-level health uses ethnography and interviewing to understand drivers of health disparities; reduces barriers to receiving coordinated, culturally, and linguistically appropriate clinical care; promotes healthy behaviors in the community through targeted dissemination and interventions (e.g., farmers' markets, partnering with community activists to promote healthy eating and physical activity)
From page 34...
... At Health Share, the CAC members are strategically recruited to reflect the diversity of the community across multiple axes of diversity, including race and ethnicity, age, gender, sexual orientation, and geographic location. Among other duties, the CACs are tasked with conducting a community health assessment to identify community needs and developing a community health improvement plan to address health disparities.
From page 35...
... . Specific activities into which leaders can incorporate the aim of achieving health equity to support organizational transformation to achieve a culture of equity may include • Investing in a diverse workforce to provide culturally concordant and culturally competent care and improved communication; • Designing interventions to reduce health disparities • Redesigning care to incorporate equity goals; and • Setting measurable goals to reduce health disparities and holding staff accountable Workforce Investments to Promote Health Equity Initiatives targeted at enhancing workforce capacity to reduce health inequities include investments in additional staff such as hiring language interpreters or clinical and non-clinical staff from diverse backgrounds as well as staff development activities such as providing education, trainings, and other resources for staff (IOM, 2003)
From page 36...
... A study identifying themes from systematic reviews of interventions to reduce racial and ethnic disparities found that successful interventions involved the active design of interventions to reduce disparities that were targeted to specific contexts, patient populations, and organizational settings (Chin et al., 2012)
From page 37...
... In response, the organization's executive leadership and governance recognized changes to its patient population, acknowledged and accepted accountability for existing health disparities, and acknowledged that providing equitable care was a strategic issue and part of its organizational vision. In addition, the organization believed that there were business, legal, and quality improvement rationales to provide equitable care.
From page 38...
... , as well as providing trainings, educational opportunities, resources, and other tools to increase awareness of health disparities and solutions. These tools include language trainings accompanying the expansion of interpreter staff, educational forums about social risk factors for poor health, and cultural competence training.
From page 39...
... Because a commitment to health equity acknowledges that social processes drive inequalities in health, to reduce health inequities and improve care for socially at-risk populations, organizations may be motivated to acknowledge the social context of their patient populations and even address social risk factors for poor health outcomes (Bachrach et al., 2014)
From page 40...
... . However, a systematic review of interventions to reduce racial and ethnic disparities in diabetes found that providing in-person feedback to providers about their performance improved diabetes outcomes for African-American patients (Peek et al., 2007)
From page 41...
... . Together, this literature suggests that collecting consistent data by social risk factors and disaggregating data by indicators of social risk may also be critical for improving care for socially at-risk populations.
From page 42...
... that may not be identified through clinical data alone. Thus, comprehensive needs assessments may need to include not only consideration of clinical and behavioral risk factors as is done for the general population, but also social risks that may be related to health care outcomes.
From page 43...
... Recommendations for conducting these assessments suggest that important components include defining the community; building shared ownership of community health and shared commitment to improving community health; data collection using shared measurement; data analysis, including stratified reporting by indicators of social risk, identification of assets, capacities, and unmet needs; defining priorities and a plan to address unmet needs; and engaging the community through continuous communication throughout all stages of the needs assessment and dissemination of results (Barnett, 2011; CDC, 2013; CHA, 2013; Myers and Stoto, 2006; Rosenbaum, 2013)
From page 44...
... Collaborative Partnerships Improving health and health care outcomes for socially at-risk populations will require collaboration within and between care teams within health systems, across clinical settings, and between health systems and external partners, such as community organizations and public health and social service agencies (Bachrach et al., 2014; Schor et al., 2011)
From page 45...
... . Similarly, a systematic review of interventions to improve asthma outcomes among racial and ethnic minority adults found that Health Resources and Services Administration Health Disparities Collaboratives, established to bring together CHCs to share knowledge and disseminate quality improvement techniques, showed potential to improve quality of care (Press et al., 2012)
From page 46...
... ; invested in HIT infrastructure to integrate information from and facilitate coordination across clinical, behavioral and social services; and expanded its workforce to include specialized nurse care coordinators, pharmacists, dentists, behavioral health staff, social workers, community health workers, housing and social services navigators, vocational counselors, emergency medical services staff, and HIT professionals (Sandberg et al., 2014)
From page 47...
... Stout Street Health Center provides health care services, including primary care, mental health care, substance abuse treatment, dental and vision care, and social services to about 18,000 current homeless persons, formerly homeless persons residing in coalition residences, and formerly homeless persons who no longer live in coalition residences. The health center assigns patients to a care team that includes a primary care physician, a physician's assistant, a social worker, and part-time psychiatrists and pharmacists who coordinate to provide physical and behavioral health services.
From page 48...
... , such as through the use of coordinated care teams, trained care coordinators, and patient navigators, or through collocating services. A review of randomized controlled trials of interventions to improve care transitions among chronically ill adults found that all but one trial showed positive effects on at least one outcome -- clinical outcomes, patient experience, quality of life, health care use, and costs -- regardless of the specific type of intervention (e.g., discharge planning and follow up, case management, coaching, patient education, peer support, telehealth)
From page 49...
... . BOX 2-6 Care Continuity Case Study: Geisinger Health Plan's Medically Complex Medical Home Program Geisinger Health Plan is a nonprofit health maintenance organization that serves beneficiaries in Delaware, Maine, New Jersey, Pennsylvania, and West Virginia.
From page 50...
... to ensure the provider can find the patient. Specific types of activities providers may practice to engage patients in their care and to support individuals in the community include educating patients about selfmanagement, healthy behaviors, and care coordination; providing culturally sensitive, targeted, and tailored patient education; providing tailored care plans easily understood by patients; employing patient navigators or health navigators to facilitate access to and to coordinate care between clinical and social services; using new technologies (e.g., telephone consultation, videoconference, mobile screenings, smartphone apps)
From page 51...
... . With respect to patient navigators alone, studies have shown that employing patient navigators or care managers to facilitate access to clinical and social services, coordinate care, and support self-management has shown promise to improve care for high-cost Medicare beneficiaries and to reduce racial and ethnic disparities (Chin et al., 2012; Davis et al., 2015; Itzkowitz et al., 2016; Naylor et al., 2012)
From page 52...
... Genesys Health System, a nonprofit, integrated health care system, developed the model to improve the health of residents of Genesee County, Michigan, which covers the greater metropolitan area of Flint. As part of the model, Genesys HealthWorks implemented an integrated self-management support program using health navigators to support patients to adopt healthy behaviors such as physical activity and healthy eating and to reduce health risks like tobacco use.
From page 53...
... As described in detail in the preceding sections, the specific interventions appropriate to a given care setting will depend on the specific needs of a provider's patient population, each individual health care provider's available resources, and the local community context. Table 2-2 provides working examples of systems practices applied to reducing readmissions in the hospital setting and to improving diabetes care in the outpatient setting.
From page 54...
... care teams and community health workers when appropriate. Tailor care to Dietary recommendations are tailored to reflect patient reflect the social preferences.
From page 55...
... The hospital employs community health workers blood pressure to supplement primary care clinic visits. The sectors to deliver linked to the care team to provide home-based health ACO or health plan employs community health workers linked care.
From page 56...
... care: Design living in the community that can support patients' self- Enhanced use of mobile applications and sensors enable patients individualized management and help reduce their risk of readmission. to record and communicate their home glucose and blood care to promote The patient's care team carefully reviews the patient's pressure readings to their primary care teams and receive realthe health of functioning in daily life (e.g., giving attention to memory time guidance on medication changes and lifestyle modifications individuals in the loss, help with activities of daily living, or limited English to improve their diabetes control.
From page 57...
... Although the evidence on the effects of these practices to improve care is limited, these systems practices and the overall systems approach the committee proposes can be used to generate testable hypotheses. In other words, these practices and the systems approach can also be seen of as aspirational and innovative service delivery models that can be rigorously evaluated with respect to their potential to improve or achieve high-performing care for socially at-risk populations and to reduce health inequities, as well as the resource requirements to do so.
From page 58...
... n.d.-b. Geisinger Health Plan's medically complex medical home program.
From page 59...
... 2013. Community health assessment for population health improvement: Resource of most frequently recommended health outcomes and determinants.
From page 60...
... 2002. Systematic review of involving patients in the planning and development of health care.
From page 61...
... 2013. Health information technology capacity at federally qualified health centers: A mechanism for improving quality of care.
From page 62...
... 2011a. HHS action plan to reduce racial and ethnic health disparities.
From page 63...
... 2016. New york citywide colon cancer control coalition: A public health effort to increase colon cancer screening and address health disparities.
From page 64...
... 2015. Community health initiatives.
From page 65...
... 2008. Beyond equal care: How health systems can impact racial and ethnic health disparities.
From page 66...
... 2016. Accounting for social risk factors in Medicare payment: Identifying social risk factors.
From page 67...
... 2012. Interventions to improve decision making and reduce racial and ethnic disparities in the management of prostate cancer: A systematic review.
From page 68...
... 2007. Reducing health disparities in depressive disorders outcomes between non-hispanic whites and ethnic minorities: A call for pragmatic strategies over the life course.


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