Integrated Framework for Reducing Racial and Ethnic Disparities in the Quality of Health Care (Text Version)

On September 28, 2010, Marshall H. Chin and Donald Goldmann made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (511 KB).

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Slide 1

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

Four images are shown: 1. An image or a nurse taking blood pressure; 2. 3 people sitting around a table; 3. A mother and daughter waiting in a waiting room; and 4. A doctor and a nurse smiling.

Slide 2

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.

Slide 3

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.

Slide 4

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.

Slide 5

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.

Slide 6

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

Slide 7

Planned Care Conceptual Model

An image of the planned care conceptual model is shown. The model consist of the following fields.

• Organization of Health Care
  • Health System
    • Self-Management Support
    • Delivery System Design
    • Decision Support
    • Clinical Information Systems
• Community
  • Resources and Policies

• Informed, Activated Patient
• Productive Interactions
• Prepared, Proactive Practice Team

Functional and Clinical Outcomes

Slide 8

New IOM Framework

An image of the IOM Framework is shown.

Crosscutting Dimensions	Components of Quality Care	Type of Care
		Preventive Care	Acute Treatment	Chronic condition management
Equity	Value	Effectiveness
		Safety
		Timeliness
		Patient/family centeredness
		Access
		Efficiency
		Care Coordination
		Health Systems Infrastructure Capabilities

www.SolvingDisparities.org

Slide 9

RWJF Finding Answers
Conceptual Model
Chin et al. Med Care Res Rev 2007; 64:7S-28S

A diagram of the RWJF Finding Answers Conceptual Model is shown:

Slide 10

Systematic Reviews

• Reviewed 200+ articles
• Condition-specific:
  • Cardiovascular disease
  • Diabetes
  • Depression
  • Breast cancer
• Cross-cutting
  • Cultural leverage
  • Pay-for-performance incentives
• FAIR Database

A cover of a book titled "Medical Care Research and Review" is shown.

Slide 11

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.

Slide 12

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.

Slide 13

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.

Slide 14

Integral Components of Systems Approach to Reducing Disparities

1. Examine your performance data stratified by insurance status, race/ethnicity, language, and socioeconomic status.
2. Get training for your staff to work effectively with diverse populations.
3. 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.

Slide 15

Systems Approach—2

4. Provide models of care and infrastructural support to enable organizations to improve the quality of care for vulnerable patients.
5. Align incentives to reward providers and health care organizations for providing high quality care to vulnerable populations.
6. Allocate more resources for the uninsured with chronic diseases.

Slide 16

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.

Slide 17

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?

Slide 18

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.

Slide 19

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.

Slide 20

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?

Slide 21

Spheres of Influence for Disparity Interventions

• Patient/person
• Provider
• Microsystem
• Health care delivery organization
• Community and region
• Policy, payment, regulation, accreditation