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- Intent to apply (not mandatory)-Due December 13, 2013
- Application (Includes Intent to Apply form) - Due February 14, 2014
Question 1: Please include a brief description of your organization (limit 500 words). Please be sure to include the following:
- Type of organization (e.g. Medicaid health plan, public or private hospital, FQHC community health center, federal or local government agency)
- Demographics of the population that your organization serves
- Type of services your organization provides
- Geographic location of services provided
- Mission of the organization as relevant to the DLP
XX is a not-for-profit organization serving all of XX. It is the state’s leader in health care financing with nearly 3 million members. Founded in 1945, XX has more than 4,700 employees and is headquartered in XXX with regional offices throughout the state. More than 17,500 companies have benefits provided through XX. The company paid approximately 59 million claims and $17 billion in health care benefits in 2007. XX is the largest XX (Medicaid) provider in the state with 302,000 members. XX’s service network includes in excess of 150 hospitals, 19,100 physicians, and 2,100 pharmacies. An active supporter of community efforts, XX contributes $4.8 million annually to charities and sponsors various programs designed to promote fitness in XX. We also have a number of initiatives currently underway to address the affordability of health care within the state. One way we support diversity is through our supplier diversity program. This effort provides maximum opportunities for small, minority, women, and veteran-owned businesses to participate with XXX as suppliers, contractors and sub-contractors. We also have a dedicated diversity area serving our employees as well as a task force, which I chair, working to improve cultural competence among XX providers.
XX is a comprehensive pediatric medical center that is the only free-standing children's hospital between XX and XXr. We are consistently ranked among the leading children's hospitals in the nation, and we were the first hospital in XX or XX to receive the prestigious Magnet designation for excellence in patient care from the American Nurses Credentialing Center. We provide state-of-the-art care for children from birth to age 18 who come to us from throughout XX and XX and beyond. In addition to the clinical expertise provided by our pediatric specialists, XX is also a leader in providing pediatric medical education to the physicians and nurses of the future and in conducting cutting-edge pediatric medical research to discover the treatments and cures of tomorrow. And XX is nationally recognized for our innovation in creating a family-centered environment that is focused on the unique needs of hospitalized children and their families.
XX is a not-for-profit institution serving as the safety net hospital for the indigent under- and uninsured population throughout the region. The hospital was founded by two women in the late 1800’s to serve otherwise neglected children and we are proud to have continued and built on this tradition of accepting all who enter our doors. We have a long history of grass-roots efforts to improve our services to those who may not feel “at home” in our health care system. Until now, we have had no formal infrastructure with administrative support meant to address the issues of equity, diversity, and disparities. Thankfully, we have won the backing of our CEO and have a solid champion in the Executive Vice President of Patient Care Services, a nurse educator with a passion for this and many other patient-oriented challenges.
Hospital - XX is comprised of five hospitals and 23 offsite clinics. It is the teaching hospital for the XX, and the only public and teaching hospital in the state. Only 30 hospitals in the United States are both public and teaching facilities. We have approximately 618 beds and 5600 employees. In Fiscal year 2008, we provided 163,000 patient days, 450,000 clinic visits and 86,000 Emergency room visits. XX Hospitals is the only Level 1 trauma center in XX, has the state’s only full service Children’s Hospital, and only adult psychiatric emergency department. In 2007, our Cancer Center was named one of the 50 best in the nation. We have also been honored as one the Most Wired Hospitals in the nation, Top 125 Training Organization, and most recently one of the Top 100 Hospitals to Work For by Nursing Professionals Magazine. We were also one of five programs spotlighted in the HRSA biennial report to Congress on the Ryan White HIV/AIDS program as the premier program in reducing disparities in access to high quality health care by people with HIV.
We are a regional leader in language access, with 15 full-time interpreters in Spanish, Vietnamese, and Navajo. We have 24-hour coverage, by offering interpretation through live video interpreting, contracted telephone interpreting, and use of over 300 bilingual employees who are tested and qualified in over 10 different languages. XX is one of the two majority-minority states in the nation, and the only majority Hispanic/Latino state (at 44%). Among our employees, Whites are somewhat overrepresented compared to the rest of the state and our patient population, Hispanics slightly underrepresented, Native Americans are very underrepresented, and African Americans and Asians representative.
Question #2: Please describe the focus (limit 500 words) of the strategic plan or project you will take on through the DLP. You may choose to address broad systemic issues (e.g. developing a strategic plan to improve quality and address disparities, collecting race/ethnicity data, or stratifying measures by race/ethnicity/language) or a particular disparity you have identified (e.g. population management in diabetes, preventable readmissions, ACS, colorectal cancer screening).
In an effort to ensure that all patients have the same standard of quality, safety and customer service, we have carved out Heart Failure as a separate evidence based service line within the Cardiology division. This patient centered approach has resulted in the enhanced care for patients with Heart Failure in two major areas. Our first step was the creation of an outpatient Heart Failure clinic. The Heart Failure clinic is committed to assisting patients so that they can not only successful assume their self management role, but advocate for their needs across a continuum of care settings. As a strategy of averting early re-admission, we routinely schedule a follow appointment within a week of hospital discharge, patients will be seen in the Heart Failure clinic. An Internist or advanced practice nurse in concert with a clinic pharmacist participates in a systematic approach to changes in patient status. These include the following areas: (1) To assess factors contributing to left ventricular dysfunction (2) to examine current circulatory status, (3) to evaluate related risks such as dysarrythmia, risk for embolic events and recurrent ischemic attacks, (4) to define goals for ongoing therapy, (5) to review patient preferences for end-of-life decisions and (6) non-adherence and factors that contribute to it.
We have also implemented a patient centered inpatient checklist to promote mastery over the fundamental concepts of CHF during their hospital stay. Outpatient case managers will assist patients in navigating our patients through the various care transitions while ensuring that the medical home is kept abreast of clinical developments.
We are currently implementing a robust system of care for our most vulnerable patients with Heart Failure. However, as we embark on this journey, is it apparent that we lack any reliable information and systems to address the disparities that every medical provider knows exist. We would like to incorporate attention to the issues of disparities early on in the Heart Failure Program to ensure that the philosophies and tools acquired from the Disparities Solutions Center are successfully incorporated into and sustained in our system of care. The goals for our specific disparities in CHF project are:
- To determine whether disparities in cardiac service utilization exist throughout the hospital by implementing a standardized process to collect race/ethnicity and language data for patients with Heart Failure.
- To develop a strategy to report this information by utilizing the Disparities Dashboard format.
- To feed-back the observations identified in specific aims #1 and #2 in order to reduce in-patient re-admission and enhance the quality of life for patients with Heart Failure.
In late 2006, our health plan conducted a series of market research interviews with African American, Caucasian and Latino members with diabetes. The goal was to assess factors/drivers that contributed to members’ ability to successfully make lasting lifestyle changes to manage diabetes. The results clearly indicated that a significant knowledge and support gap existed for minorities with diabetes. Based on feedback gathered from the interviews, the disease management/health education subsidiary of our health plan embarked on a year-long planning process to design a large-scale pilot project tentatively entitled “Commitment to Change: Enhancing Health Care Equity Across Racial/Ethnic Groups.” The project is to be a collaborative effort among and between the various arms under the health plan’s umbrella.
Specifically, our overarching study question is: “How do culturally relevant strategies for African Americans and Latinos with diabetes impact member engagement and health outcomes (proximal, intermediate, and long-term)?” The pilot project will integrate services provided across XXX such as pharmacy management and behavioral health services that would help provide full-spectrum support to diabetic members with culturally and linguistically relevant materials.
In scope (initial pilot project
- Patient/member/participant-level strategies to enhance engagement that can be replicated nationally on a large scale
- Commercial (private) medical insurance
Out of scope (initial pilot project)
- Provider education (diabetes knowledge and patient-centered communication skills)
- Local or community-based initiative
Initial research within the XXX has previously identified health equity improvement opportunities within inpatient and ambulatory care delivery processes. More recently, the XXX Office of Health Equity has developed an Equity Performance Analysis Model enabling the identification and communication of Health Equity Improvement targets among 13 JCAHO inpatient core measures and 10 ambulatory preventive health services measures (as recommended by the U.S Preventive Health Services, 2nd Edition). Applying the Equity Performance Analysis Model within XXX has identified opportunities for care delivery health equity performance among the following “low performing” (i.e. <90%) inpatient health care delivery metrics: Community Acquired Pneumonia, Surgical Infection Prophylaxis, and Acute Myocardial Infarction (PTCA within 90 minutes).
The Disparities Leadership Program project we propose will relate to the design and implementation of a health care equity improvement strategy for Surgical Infection Prophylaxis (SIP). As such, we will utilize the XXX Equity Performance Analysis to identify which XXX inpatient facilities have opportunities to make improvement in reducing inequities related to providing patients surgical infection prophylaxis. The project will identify which personal characteristics (age, gender, race/ethnicity, socioeconomic status, and payer) predispose patients to receive variation in care delivery processes related to preventing surgical infections.
Once identified, a strategic improvement plan will be developed with the assistance of hospital leadership, physicians, and staff. This process will include anthropologic analysis in an effort to identify system-, staff-, and patient-level opportunities to improve care.
Community Health Center
XXX owns and operates 45 health centers in the XXX area. Our mission is to provide high quality, safe, comprehensive primary and preventive healthcare in underserved XXX area communities; we do this without regard to patients’ age, race, ethnicity, gender, religion, education, sexual orientation, physical condition or ability to pay.
As one of the largest private providers of primary health care to low-income populations in the nation, we are in a unique position to improve the health status of patients from medically underserved communities. Ninety three percent of our patients are African-American or Hispanic/Latino, and a majority live at or below 200% of the poverty level.
XXX has developed a comprehensive continuous quality improvement (CQI) program to assess the experience of our patients and our success in meeting their health care needs. In 2003, our leadership team developed preliminary quality goals based on a review of the national standards of community health care (e.g., the CDC’s Healthy People 2010), local data on health disparities (e.g., diabetes, substance abuse, infant mortality), standards set by our accreditation agencies, and our own outcomes data. We now have several years’ experience in measuring and evaluating our quality interventions. Our next step, and the purpose of this program, is to enhance our focus on quality to include an assessment of health disparities within the populations we serve, and compared to external benchmarks. A deeper understanding of disparities will strengthen our ability to make improvements and address barriers for the most underserved.
Question # 3: Please describe (limit 500 words) how you plan to develop or implement your plan/project, including specific goals and activities you hope to achieve. We encourage you to focus your goals and activities on what can realistically be achieved in one year – we recommend no more than 2-3 milestones.
XXXX has clear strategic support to implement a self-reported data collection system to identify disparities among our member population, by capturing race, ethnicity, and primary language data. We are currently exploring the technical enhancements necessary for the future collection of self-reported data. To build the infrastructure and ability to detect and reduce disparities, however, we need more than just data. We propose to develop a methodology that allows for the regular reporting and measurement of disparities among XXX membership, as well as the functions to respond to identified areas of disparate care and outcomes.
To begin the development of this action-oriented infrastructure, we are preparing for a collaborative project 1) to indirectly collect member race and ethnicity data through geo-coding and surname analysis, and 2) to map performance measures of diabetes care in targeted markets, stratified by race/ethnicity, to determine areas characterized by disparate care and outcomes among racial and ethnic subgroups. We intend to use the indirect data project as a model for our future disparities work, while mitigating our lack of primary data. Based on the results of this initial analysis, we aim to deploy a culturally-tailored clinical intervention to close the identified gaps in care among diabetic members in specific markets. This effort will serve as a pilot attempt in our efforts to engage subpopulations in culturally-appropriate ways. It will prepare us to address greater gaps among our membership, across conditions and populations, once we have a larger repository of self-reported member data.
Our goal for the Disparities Leadership Program is to build a rules-based process that uses race and ethnicity data and clinical cues to identify disparities of care. The next part of the process is to determine the requirements for member engagement according to CLAS standards, in order to improve quality and outcomes. This may involve identifying appropriate resources for practicing cultural competence in our clinical services. This proposed system should also include evaluation methods to assess the impact of culturally-sensitive engagement on racial and ethnic disparities. We anticipate that participation in the DLP will provide expertise on best practices for developing such as system.
Community Health Center
XXX has begun the process of examining health disparities, but is really just beginning this process. It has in place an infrastructure that will enable continued attention and increasing sophistication in this task.
The rough plan for addressing our project is as follows:
We would like to start by further examining the disparities in process and outcome measures for our Black patients with hypertension and diabetes, whom we believe receive the same care as other clients but for whom blood pressure control, for example, is significantly poorer than their counterparts of other racial and ethnic groups. Our Biostatistician/Epidemiologist will help us to delve deeper into this issue to better understand potential differences in health care utilization patterns, medication compliance, the use of support services, etc. that may help us design interventions that will be useful in reducing disparities. Once we are able to develop a model for examining disparities, we would like to expand to other outcome and process measures in chronic disease management, and similarly, to design and test interventions aimed at reducing the disparities we study.
Our hope is that by participating in the DLP, we will have an opportunity to become more familiar with the body of work on the issue of health care disparities so as to inform our thinking about possible causes and interventions, to discuss our ideas with others with similar interests, and to receive feedback and suggestions as to strategies and approaches.
To conduct our organizational assessment, we will first interview key leaders in both XXX and XXX regarding disparities activities. Using the list generated from these discussions, we will conduct additional interviews oriented toward better understanding those activities, and to help identify additional disparities efforts. We will catalog activities along multiple dimensions (e.g., what they are, who leads them, who the audience is, what measurable outcomes are involved, what information they produce, how they inform future practice) and prepare a written summary of all activities identified for Hospital and the Medical School senior leadership.
To explore information technology strategies to improve performance and decrease disparities, we will identify clinical issues among the common reasons for MassHealth
discharges, which are likely to be treated by the internal medicine service at the hospital (our home department, where we choose to initiate our focus), and we will identify indicators best suited to IT supported intervention. For example, we may choose to focus on the clinical issue of community acquired pneumonia, the 7th most common discharge diagnosis for MassHealth in 2005. MassHealth and the IOM Performance Measurement Report both list ED blood culture collection prior to first administration of antibiotic in the hospital as an important quality indicator. Since both testing and prescribing are completed through Computerized Physician Order Entry (CPOE) at XXX, we could develop and implement disparities focused Clinical Decision Support algorithms to prevent antibiotic prescribing for patients with pneumonia if a blood cultures have not been previously performed.
Third, we will use data collected through Dr. X’s funded R01 to evaluate efficacy of a brief communication skills training intervention designed to improve counseling skills focused on antihypertensive medication adherence and coupled with electronic reminders to counsel patients, soliciting patients’ evaluations of their providers’ cultural competence and patient’s reports of specific issues discussed with their providers during clinic visits (note: these assessments were developed in collaboration with Dr. Alex Green). We will look for intervention associated improvement in physician-patient interactions, increased patient satisfaction with care, patient assessments of racial discrimination, and ultimately, whether adherence to BP medications or BP control improved.
Question #4: What resources (institutional infrastructure, human resources, time and/or financial) are available for this effort (limit 250 words)?
XXX CLAS Resources already include the following:
- Facility language access coordinators (convened regularly)
- THE XXX interpreting center: 25 interpreters who provide interpretation in 7 languages: Spanish, French, Haitian-Creole, Polish, and Chinese (mandarin, Cantonese, and Fukienese)
The CLAS Staff:
- XXX – Senior Director CLAS Office
- XXX – Director, Interpreter Standards and CLAS Best Practices (on-site) Consulting, CLAS Office
- XXX – Associate Director, CLAS Office
- XXX- Executive Assistant, CLAS Office
- Leadership, represented by XXX, Executive Vice President & Chief Corporate Medical Officer
The three participants in the DLP, XX, XX, and XX, are committed to spending the necessary time to bring back ideas and test improvements. As the President and CEO, X’s participation will give this issue the prominence it deserves as an important priority of the Health Center. X and X are members of the Heart Matters quality improvement team, the team that has been responsible for trying and testing changes in the provision of care to patients with diabetes and hypertension. Of particular importance is financial support from the XX. Currently, XX funding supports the salary of a part-time biostatistician/epidemiologist who will play a pivotal role in the kinds of analyses we hope to do in the DLP.
Question #5: Please describe (limit 250 words) your organization’s commitment to this effort. What level of leadership is involved? How will the effort be promoted within the organization? What will be done to help the project succeed?
In 2006, XXX formed a cross-functional committee to build a strategy to address disparities, with input from representatives from across the company. This cross-functional committee allows us to address provider-, member-, and associate-focused strategies in order to build awareness and momentum around our disparities work. Our Corporate Medical Director is responsible for the oversight of this committee’s activities. Likewise, this committee maintains a relationship with XXX’s Diversity Board of Directors to socialize the issue across the company and leadership. Humana’s current efforts to address disparities include:
- participation as members of the National Health Plan Collaborative (NHPC)
- participation on two AHIP advisory disparities taskforces
- providing cultural competence resources and training to associates
- evaluating translation services and language access
- determining system enhancements that are necessary to collect and store self-reported data
XXX has recently received executive-level support for the collection of self-reported member race and ethnicity. Building the place-holders for race and ethnicity in our data warehouse is a considerable technical undertaking. This enhancement is being implemented in conjunction with other enterprise-wide system enhancements in order to ensure the update is operational. XXX’s Clinical Guidance Organization supports the goal of using this data to target at-risk members for culturally-appropriate clinical programs and interventions. Our next phase is to identify and complete the necessary system enhancements to populate the data fields with race and ethnicity from a variety of portals. XXX’s collaboration with external organizations, such as the NHPC and AHIP, help drive internal commitment to these efforts and provide transparency around our work to address disparities.
Community Health Center
Our President and CEO, has been a strong voice for understanding clinical outcomes by race and ethnicity for years. Her leadership has been critical in moving forward the electronic medical record, and in using it as a tool to measure our performance. With her guidance, we have begun to examine clinical outcomes and to try to understand what the contributors are to the differences by race/ethnicity we have seen in these outcomes. Our first effort to understand race/ethnicity differences in outcomes has been in the areas of diabetes and hypertension, and as we have looked at this data, the members of our Heart Matters quality improvement team have become very interested in why we are seeing disparities and what we can do about them. We have the resources and infrastructure in our chronic disease management program--medical providers, chronic disease nurses, stress management counselor, Tobacco Treatment Specialist, nutritionist, optometrist, podiatrist, as well as exercise classes, membership to YWCA, personal trainer and a variety of other services--to develop a disparities intervention. Our ability to collect process and outcome data by race/ethnicity will allow us to evaluate the effectiveness of disparity interventions over time. Finally, our Medical Director and medical staff are aware of the disparities in outcomes and would like to understand more and to address these disparities. The buy-in of the medical staff is critically important and will be a major factor in the success of the project.
This project has support from the highest levels within each institution. X, Chairman of Medicine, is a consistent and vocal champion of the need for better coordination and recognition of the ongoing disparities efforts, and he has taken the lead in providing resources for the hiring of a new senior leader in disparities, and in supporting our involvement in this leadership program (including willingness for some of our time to be devoted to this effort).
Similarly, we enjoy support from the highest levels of the hospital administration. X, Chief Information Officer, has also indicated her willingness to financially support our involvement in this program, and to support some of Dr. X’s time in these efforts. Another strong example of X’s commitment to addressing racial and ethnic health care disparities has been its purchase and mandated utilization of the MGH/DSC CME On-line Cultural Competency training program for institutional attending physicians. Further evidence of institutional commitment to disparities work is that X and the Department of Medicine are actively collaborating to identify and solicit additional funding for a free-standing Disparities Data Warehouse that will meet the needs of patient care/ systems improvement as well as ongoing research oriented efforts. The ability of this tool to aggregate and analyze clinical data along with racial and ethnic markers will greatly facilitate examination of quality indicators, performance metrics, and through various stakeholders will facilitate the evaluation of and intervention upon health and healthcare disparities.
Please visit our DLP alumni page, for more information on past participants, including a list of our current class.