Eliminating Healthcare Disparities: How Kaiser Permanente & Trinity Health Close Racial Gaps

These companies are working to bring meaningful and effective care to at-risk populations that face barriers in income, language or culture.

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Imagine a medication that could drastically reduce your risk of stroke. Now imagine not having access to it. Thousands of Americans with diabetes and heart disease are at increased risk for stroke, but many lack access to treatment because of barriers in income, language or culture.

Thanks to an initiative from Kaiser Permanente's Care Management Institute, a simple, low-cost preventative treatment is becoming more readily available, especially to traditionally underserved populations, including Blacks, Latinos, Asians and American Indians. Before the program came to Clinica Family Health Services outside of Denver, only one-third of the eligible candidates were taking the medication, says Dr. Winston Wong, director of Disparities Improvement and Quality Initiatives at Kaiser Permanente, No. 1 on The 2011 DiversityInc Top 50 Companies for Diversity list. Two years later, Clinica, which primarily serves the working poor, saw the number of people on the regimen double, reducing the chance of heart attack and stroke by 50 percent in hundreds of patients. For more on Kaiser Permanente's best practices, read What Makes Kaiser Permanente Score With Employees, Customers?

This effort to bring meaningful and effective care to at-risk populations was a patient-centered one. Practitioners were able to engage patients and empower them to take a role in their own health. "They really showed us that it is achievable to get this level of therapy to communities that are typically perceived as difficult to work with," says Dr. Wong. "Because of the way they adapted our program, they accomplished great results." The success of Kaiser Permanente's intervention, which won the Care Continuum Alliance's Quality Impact Award in 2010, shows that proper stroke prevention is often a matter of delivering the right care to the target population. When practitioners make the effort to engage and connect with patients, they build bridges to quality care.

Kaiser Permanente's program shows that incorporating patient values as well as demographic information into medical outreach can improve health outcomes. Unfortunately, the struggle to reach traditionally underrepresented groups is an uphill battle. "Part of the issue around healthcare disparities has to do with the disproportionate number of communities of color that are uninsured," says Dr. Wong. "There's not actually a level playing ground."

The Racial Divide

A recent report by the Centers for Disease Control and Prevention finds that Latinos and Blacks have significantly higher uninsured rates than other groups. Latinos alone account for one-third of the uninsured population in the United States. But even when these groups receive care, it is often a worse standard of care, according to a 2010 report published by the Agency for Healthcare Research and Quality. Latinos receive worse care than whites for about 60 percent of health measures, such as cancer screenings, while Blacks and American Indians receive worse care than whites in about 40 percent of measures. Low-income people are hit the hardest, receiving worse care than their more affluent counterparts for roughly 80 percent of the health measures.

Although the numbers seem bleak, two healthcare companies are leading the charge in their efforts to address these gaps in coverage among different groups. By investing in education and training, cutting-edge technology and community outreach, Kaiser Permanente and Trinity Health are chipping away at these barriers to equal care.

With closing the gap in mind, Oakland, Calif.–based Kaiser Permanente performs a detailed analysis of the demographics of its roughly nine million members. Combing the data helps them to identify and address barriers to the care of traditionally underrepresented groups. "We're thinking about how to customize care for patients from different cultural, socioeconomic and linguistic backgrounds and to look at that in a very systematic way," says Dr. Wong. For example, if certain groups are routinely not getting screenings for breast cancer, clinics can make an effort to reach out to these populations and figure out better ways to communicate with them. It's a matter of studying population patterns to identify where improvement is needed, says Dr. Wong, adding that today's technology enables doctors to "see things at a 10,000-foot view."

The Personal View

While Kaiser's vast practitioner network is honing this macro view of data, Trinity Health is focusing on the micro by streamlining the collection of patient demographic information on the individual level. With 47 hospitals and hundreds of clinics, Trinity Health is one of the largest Roman Catholic healthcare systems—and the 12th largest health system—in the United States. The Novi, Mich.–based company unveiled the Equity in Care project in 2010, requiring its staff to electronically record patient language preference and other demographic information at check-in. This involved training patient registrars to collect information in a standardized and culturally appropriate way. Research has shown that when doctors know a patient's race, they can personalize care based on known illnesses that exist in different groups, says Antoinette Green, Trinity's vice president of diversity and inclusion. "The goal is to create a workplace of cultural competence that is delivering the highest quality of care to every patient regardless of race, ethnicity, culture or language," she says.

Targeting certain groups based on their known risk factors for disease is an important way to keep both doctors and patients informed about proper prevention. For example, American Indians are twice as likely as whites to have diabetes. In fact, nearly 18 percent of the American Indian population is suffering from diabetes, according to a 2008 publication of the Commonwealth Fund. The paper also found that nearly 15 percent of Blacks and 14 percent of Latinos have been diagnosed with diabetes, compared with only 8 percent of whites. Heart disease and stroke are also a source of inequality among Blacks and whites, according to a 2011 report by the Centers for Disease Control and Prevention, which states: "Coronary heart disease and stroke are not only leading causes of death in the United States but also account for the largest proportion of inequality in life expectancy between whites and Blacks, despite the existence of low-cost, highly effective preventive treatment."

The Center of the Storm

Achieving equity in care means supporting underserved populations where they live and work and allocating resources to the front lines. Last year, Kaiser Permanente granted $70 million to its Safety Net partners—community clinics, public hospitals and health centers that treat underserved people. "These organizations are really at the center of the storm when it comes to caring for people who are uninsured," says Dr. Wong. Funds from Kaiser help these centers make improvements in acute and chronic care, prevention, outreach, patient experience and clinical outcomes. "It's really a rich set of different activities that are being supported through a pretty robust grant-making mechanism," Dr. Wong says.

Trinity also has several outreach programs that bring top-notch medical care to diverse communities. In 2011, the company's Community Benefit Ministry spent $454 million on programs geared toward poor people and those who are uninsured. That includes Trinity's 13 specialized emergency departments that focus on senior citizens and the installation of Community Connection Kiosks that connect underserved patients with local social services. In addition, Trinity's Holy Cross Hospital near Washington, D.C., uses community-based ethnic health promoters to reach out to local communities that have reduced access to healthcare because of income, language barriers or cultural differences.

Kaiser has a similar program with its promotoras model—lay health workers who are typically bilingual and live and work in the communities that they serve.

But investing in healthcare equity goes far beyond dollars and cents. It's about emphasizing the importance that cultural differences play in the kind of care we seek out and the kind of care we receive. With this in mind, Trinity Health recently launched an interactive online course to educate doctors about cultural awareness. "We are creating a workforce that will be culturally competent and ready to deal with the shifting demographics in the United States," says Green.

Kaiser is also helping to re-shape the health industry with an emphasis on patient-centered care through its own cultural-competence programs, scholarships to Safety Net partners, and taking a close look at demographics to measure and improve access to services and target care across their diverse membership.

"It's not about doing the same things you've always done," says Dr. Wong. "I don't think that's the answer. The answer is reconsidering how you do things—redesigning how we work with patients, how we incorporate diversity into providing care—that enables us to close the gap."

Moving Forward

A unique program at one of Trinity Health's hospitals shows how taking into account a physician's background can improve the doctor/patient relationship. This fall, The Wall Street Journal highlighted a cultural-competency course developed at Trinity's Mercy Medical Center in Mason City, Iowa. Roughly a quarter of physicians in the United States are foreign born, and the number is even higher in rural communities such as Iowa. Sociologists at the University of Iowa found that Mercy's diverse group of doctors often struggled to relate and communicate with a patient base that was predominantly white and rural. A new cultural training program helps foreign doctors, such as Egyptian pediatrician Dr. Adel Makar, better understand his patients. "There are misconceptions on both sides," he told The Wall Street Journal. "It's good we start to talk about it openly."

Dr. Wong agrees that cross-cultural understanding is a win-win. "The lessons we learn from the diverse nature of our membership accrue benefit for everybody," says Wong. "If I'm able to figure out how I can make an immigrant from India feel like he's getting top-notch care, I should be able to translate those ways of understanding to a person who's been in the United States for six generations."

To measure progress in closing the gap, Kaiser uses an "equity dashboard"—a quarterly transparent set of measures that focus on inpatient and outpatient care. The dashboard enables Kaiser to identify gaps in clinical outcomes across racial and ethnic population groups and configure strategies to address disparities. "Obviously, we want to trend upwards," Dr. Wong says. For example, practitioners at Kaiser wanted to know if health outcomes were different when a physician spoke the same language as a patient. The data suggests that when doctors and patients speak the same language, patients are less likely to break appointments and patient satisfaction is higher, says Dr. Wong. With this knowledge, Kaiser can develop specific programs to give non-English-speaking patients better care.

In order to keep its goals for healthcare equity on track, each of Trinity's hospitals has a diversity leader who is required to make a three-year strategic plan that covers accountability, training and patient-centered care, says Green. "As the United States becomes more diverse, our clinicians will see more patients with a broad range of perspectives regarding health that's often influenced by their social or cultural background," she says.

In addition to reaching out to a diverse patient base, both companies have attempted to educate the wider public and shed light on the issue of healthcare disparities. In a series of full-page magazine ads in 2009, Kaiser called healthcare inequity "a national disgrace." In a powerful 2008 editorial in Modern Healthcare, Trinity CEO Joseph Swedish called upon industry leaders to forge an "especially bold and pioneering path of change" and to enact universal healthcare. Both companies have served on the American Hospital Association's Special Advisory Group on Improving Hospital Care for Minorities. Their outspoken advocacy has drawn attention to the issue, culminating in the passage of President Obama's healthcare-reform bill in 2010.

It's part of a growing corporate culture that seeks to eliminate healthcare gaps not only through investment and outreach but by espousing the notion that these inequities affect us all. "Equity is not an issue that's only for certain people," says Dr. Wong. "Equity is where we start if we're going to deliver on a promise of providing good quality care for everyone, no matter what their background is."

For more on cultural competency in healthcare, read The Business Case for Diversity in Healthcare.

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Combining data from electronic health records with results from standardized depression questionnaires better predicts suicide risk in the 90 days following either mental health specialty or primary care outpatient visits, reports a team from the Mental Health Research Network, led by Kaiser Permanente research scientists.

The study, "Predicting Suicide Attempts and Suicide Death Following Outpatient Visits Using Electronic Health Records," conducted in five Kaiser Permanente regions (Colorado, Hawaii, Oregon, California and Washington), the Henry Ford Health System in Detroit, and the HealthPartners Institute in Minneapolis, was published today in the American Journal of Psychiatry.

Combining a variety of information from the past five years of people's electronic health records and answers to questionnaires, the new models predicted suicide risk more accurately than before, according to the authors. The strongest predictors include prior suicide attempts, mental health and substance use diagnoses, medical diagnoses, psychiatric medications dispensed, inpatient or emergency room care, and scores on a standardized depression questionnaire.

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"We demonstrated that we can use electronic health record data in combination with other tools to accurately identify people at high risk for suicide attempt or suicide death," said first author Gregory E. Simon, MD, MPH, a Kaiser Permanente psychiatrist in Washington and a senior investigator at Kaiser Permanente Washington Health Research Institute.

In the 90 days following an office visit:

  • Suicide attempts and deaths among patients whose visits were in the highest 1 percent of predicted risk were 200 times more common than among those in the bottom half of predicted risk.
  • Patients with mental health specialty visits who had risk scores in the top 5 percent accounted for 43 percent of suicide attempts and 48 percent of suicide deaths.
  • Patients with primary care visits who had scores in the top 5 percent accounted for 48 percent of suicide attempts and 43 percent of suicide deaths.

This study builds on previous models in other health systems that used fewer potential predictors from patients' records. Using those models, people in the top 5 percent of risk accounted for only a quarter to a third of subsequent suicide attempts and deaths. More traditional suicide risk assessment, which relies on questionnaires or clinical interviews only, is even less accurate.

The new study involved seven large health systems serving a combined population of 8 million people in nine states. The research team examined almost 20 million visits by nearly 3 million people age 13 or older, including about 10.3 million mental health specialty visits and about 9.7 million primary care visits with mental health diagnoses. The researchers deleted information that could help identify individuals.

"It would be fair to say that the health systems in the Mental Health Research Network, which integrate care and coverage, are the best in the country for implementing suicide prevention programs," Dr. Simon said. "But we know we could do better. So several of our health systems, including Kaiser Permanente, are working to integrate prediction models into our existing processes for identifying and addressing suicide risk."

Suicide rates are increasing, with suicide accounting for nearly 45,000 deaths in the United States in 2016; 25 percent more than in 2000, according to the National Center for Health Statistics.

Other health systems can replicate this approach to risk stratification, according to Dr. Simon. Better prediction of suicide risk can inform decisions by health care providers and health systems. Such decisions include how often to follow up with patients, refer them for intensive treatment, reach out to them after missed or canceled appointments — and whether to help them create a personal safety plan and counsel them about reducing access to means of self-harm.

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