1 2013 Leadership Roundtable February 13, 2013 Health Plan Poster Series: Health Care Equity NHPC members highlight innovative programs and services designed to reduce disparities in care and address the cultural and linguistic needs of diverse populations. These programs include the collection of data on race, ethnicity and language; the development of targeted strategies to promote prevention/wellness and reduce complications due to chronic conditions; addressing workforce diversity and language needs; and establishing organizational infrastructure key to measure success and improve quality of care. Aetna AmeriHealth Mercy Family of Companies Boston Medical Center HealthNet Plan Cigna EmblemHealth Florida Blue Harvard Pilgrim Health Care HealthPartners Health Care Service Corporation Highmark Inc. Humana Kaiser Permanente Molina Healthcare Neighborhood Health Plan ODS UnitedHealth Group WellPoint, Inc. Coordinating Organization: America s Health Insurance Plans
2 ACKNOWLEDGEMENTS America s Health Insurance Plans (AHIP) would like to thank the member health plans of the National Health Plan Collaborative for their contribution in highlighting their health equity programs during the 2013 Leadership Roundtable that took place on February 13, 2013 in Washington, DC. For more information about individual health plan initiatives and programs as highlighted in the corresponding posters, please contact the health plan representative listed below. Aetna: Michele Toscano, MS, Head, Business Management and Planning AmeriHealth Mercy Family of Companies: Jenné Johns, MPH, Director of Strategic Alliances Blue Cross Blue Shield of Illinois: Araceli (Celi) Esquivel, Senior Manager, Enterprise Health Care Management Boston Medical Center HealthNet Plan: Ana Berridge, MHA, Manager of Quality Improvement Operations Cigna: Peggy Payne, MA, Director, Customer Experience Multicultural Communications EmblemHealth: Eliza Ng, MD, Senior Medical Director Florida Blue: Deborah Stewart, MD, Medical Director Provider and Client Solutions Harvard Pilgrim: Kathryn L. Coltin, MPH, Director, External Quality Data Initiatives HealthPartners: Tanya Hagre, Public Health Program Manager Highmark: Rhonda Johnson, MD, MPH, Medical Director, Health Equity and Quality Services Humana: Gertrudes T. Holder, Clinical Disparities and Cultural Diversity Consultant, Health Guidance Organization Kaiser Permanente: Gayle Tang, MSN, RN, Senior Director, National Linguistic and Diversity Infrastructure Management National Diversity Molina Healthcare: Jill McGougan, M.A., Cultural and Linguistic Specialist II Neighborhood Health Plan: Pam Siren, RN, MPH, VP, Quality & Compliance ODS: Sara E. Smith, CHES, Health Promotion and Quality Improvement Specialist UnitedHealth Group: U. Michael Currie, MPH, MBA, Director of Health Equity Services WellPoint: Grace H. Ting, MHA, Director, Health Services, Health Equity, Cultural and Linguistic Program Office AHIP staff and consultants who contributed to this publication include: Natalie Slaughter Rita Carreón Barbara D. Lardy Ted Lamoreaux Design Consultant: Wanda Ng Fontana For more information about the National Health Plan Collaborative, please contact: Rita Carreón, Director Clinical Strategies and Health Care Equity, AHIP
3 Aetna Potential Cost Savings from Addressing Disparities in Asthma Emergency Room Utilization Objective To determine the differences in asthmatic emergency room (ER) utilization between African Americans, Hispanics, and Whites in order to estimate the cost of unequal asthma care in a managed care environment. Methods 1. Identified Aetna members who self-reported their race/ ethnicity for whom there was evidence of asthma in medical or pharmacy claims during Members less than 18 years of age = 68,743; members 18 years and older = 120, Determined the number of emergency room visits per 1,000 for members with asthma for each race/ethnicity group 4. Calculated Medical Expenditure Panel Survey (MEPS) 2009 average cost of an asthma ER visit 5. Calculated excess costs associated with disparities by taking the difference in ER utilization and multiplying it by the average cost of an ER visit The cost of unequal care due to disparities in asthma ER utilization for African American adults African American vs. White estimated cost of unequal care $121,000/1,000 members = p<.0001 Statistically significant compared to White Note: Only reflects those individuals who self-identify race and ethnicity (~30% of medical membership) The cost of unequal care due to disparities in asthma ER utilization for Hispanic adults Hispanic vs. White estimated cost of unequal care $47,000 / 1,000 Members Limitations There are some limitations of the study, including the inability to assess provider characteristics, i.e., the variation in ER utilization being due to cultural differences of patients and their preferences or due to differences in outpatient providers availability for acute care visits and/or after hours care. Conclusion Through analytical methods we are able to understand the economic impact of emergency room utilization in minority asthmatic populations in a managed care environment Aetna members who had self-reported their race as African American had statistically significant higher rates of potentially avoidable ER visits (adults $121,000 / 1,000 members; children $97,000 / 1,000 members) leading to excess costs associated with asthma compared to members who self-reported their race as White Aetna members who had self-reported their race as Hispanic had statistically significant higher rates of potentially avoidable ER visits (adults $47,000 / 1,000 members; children $32,000 / 1,000 members) leading to excess costs associated with asthma compared to members who selfreported their race as White = p<.0001 Statistically significant compared to White Note: Only reflects those individuals who self-identify race and ethnicity (~30% of medical membership) Implications Extrapolating these results from the study to the US African American and Hispanic asthmatic population could identify multi-million dollars of excess costs due to unequal care There are evidence-based interventions proven to be effective that could be applied to address this issue If applied, there is a potential to improve the quality of care of this population while significantly reducing waste in terms of unnecessary health care costs
4 AmeriHealth Mercy Family of Companies Healthy Hoops Project Description Healthy Hoops is an innovative asthma and obesity management community-based program that uses basketball as a platform to teach children with asthma and their families how to manage asthma through proper nutrition, exercise and appropriate medication use. It also focuses on decreasing childhood obesity and increasing cardiovascular activity. The program includes basketball clinics for children; handson asthma education for children and parents; body mass index (BMI), asthma and various other health screenings; and nutrition information. Healthy Hoops not only enhances disease management and health outcomes, but also improves quality of life, helping children live healthier and happier lives. Program Highlights Healthy Hoops uses a holistic, innovative approach to improve quality outcomes and remove barriers to delivering asthma care by: Educating children and their families in one-to-one settings about asthma care, high blood pressure, obesity, appropriate medication use, treatment compliance and monitored physical activity. This is accomplished through health assessments and clinical monitoring to effect positive behavioral changes in the entire family. Offering families educational seminars on asthma prevention and management and home visits for environmental education and remediation of asthma triggers. Integrating community-based care by offering professional development sessions on asthma clinical guidelines for school and congregational nurses, coaches and physical education teachers, child care providers, and communitybased organizations. Providing transportation for the family and making Spanish-speaking interpreters available. Using basketball as an innovative approach to promote health management and education. Best Practices Healthy Hoops is more than just a fun-filled day of basketball activities for children it s a program that brings together a coalition of community partners to improve the health status of low income and minority Americans who suffer from acute or chronic asthma. By linking members with care managers, providers, health educators, and community-based organizations, Healthy Hoops helps establish a continuous process of engagement for members that enables them to maintain their healthy choices through the struggles of dayto-day life, and contributes to the building of the community of practice for preventive care. The Healthy Hoops program serves as an innovative solution to bridge language and cultural gaps and addresses health care disparities among racial and ethnic minorities. Since 2003, more than 10,000 children and their family members have participated in the program nationally. While Healthy Hoops is a fun program for children, it has an important message for them and their families: how to properly manage asthma through healthy behaviors such as eating habits, medication use and frequent exercise like basketball.
5 Blue Cross Blue Shield of Illinois Deploying Quality Improvement Activities to Advance Health & Health Care in Vulnerable Populations Key Physician & Provider Partnerships HMO Illinois extends training opportunity to physicians Improves culturally-competent care Offers online training Started in January 2013 Potential for 5,000 participants Multicultural Health Care Align organization for achieving the NCQA Multicultural Health Care Distinction Relies on established metrics Aligns with existing accreditation parameters To be developed over three-years Culturally and Linguistically Appropriate Services Deliver Culturally and Linguistically Appropriate Services (CLAS) through strategic partnerships in the community Grants to clinics with providers and staff that are fully bilingual and bicultural Provides culturally relevant programs focused on diabetes Illinois New Mexico Oklahoma Texas
6 Boston Medical Center HealthNet Plan Maximizing Race, Ethnicity and Language Data for Health Plan Disparities Analysis Goals Optimize the completeness of race data for Boston Medical Center HealthNet Plan (BMCHP) membership to accurately assess the quality of care among members and identify potential disparities in care across BMCHP s membership. Assess racial disparities across HEDIS quality and access measures as well as plan specific utilization measures. Impact of Supplementing Self-Reported Data with Both Alternative Methodologies The use of both methodologies resulted in an increase in the availability of race information by more than 20 percentage points. The combination of methodologies results in a distribution similar to that when using self-reported information only. Results Increased percentage of members with race data to 73 percent. The resulting racial distribution is similar to the distribution with primary data only. A significantly larger proportion of members were evaluated for disparities. Areas of disparity are in compliance and rate of compliance is similar with some reduction across groups. Racial Designation Enhancement 1. Data provided through MassHealth (EOHHS) based on member self reported data on the MassHealth benefits request form. 2. Genealogy Data used: Frequently Occurring Surnames from Census Positive predictive value of MassHealth and surname data was evaluated. Question: Does Supplemental Race Information Impact a Disparity Assessment or Rates of Compliance? Key findings The rankings of best performers are not impacted by the additional race data from the MassHealth or surname methodologies. Compliance levels drop a minimal amount with the additional data but not significantly.
7 Cigna Strategies to Improve Engagement: A Robert Wood Johnson Foundation Grant to Improve Hypertension Management Program Description Cigna was awarded a grant from Robert Wood Johnson Foundation s Finding Answers: Disparities Research for Change program to examine the extent to which a small financial incentive and educational materials can motivate physician visits, improve blood pressure control and reduce racial/ethnic disparities in hypertension. The project was administered as a partnership between Cigna and RAND Corporation. The quality improvement initiative was conducted with 18,000 individuals with hypertension in Maryland, Virginia and Washington, D.C. from Best Practices Intervention Arm 1 Intervention Arm 2 Baseline Measures Baseline Measures $15 for HTN Visit with MD Educational Materials only Post Measures Post Measures in Changes B in Changes A Post hoc analyses of patient subgroups suggested that individuals with lower elevated levels of blood pressure at baseline may have benefited from the educational materials. There is also the greatest opportunity to improve physician visits among those that have not seen a physician in over a year. These associations should be considered in future studies in hypertension management. Comparison Arm Baseline Measures Study Results Usual Care 24 months Post Measures Measure impact on race/ethnicity health disparities post intervention over 24 months Increased Physician Visits Findings suggest the financial incentive and educational materials were associated with a small increase in physician visits. The initiative had a significant effect on those who had not seen a physician in over a year. Conclusion and Recommendations This study demonstrates that resources are available in managed care organizations that can be utilized for research and testing of potential public health strategies to improve patient engagement and management of their conditions. Best practices developed and lessons learned within this setting can have practical applications to other clinical settings and populations. Improved Blood Pressure Control Financial incentives and educational materials were not associated with any improvement in blood pressure control for the full sample. However, individuals with lower elevated levels of blood pressure systolic blood pressure (SBP) between 120 and 139 or diastolic blood pressure (DBP) between 80 and 89 at baseline demonstrated significant and sustainable reductions in SBP over time. Racial/Ethnic Disparities Formal tests of interaction that compared the effectiveness of the initiative across racial/ethnic groups found no significant differences for either physician visits or reduction in blood pressure, suggesting that the initiative may not contribute to a reduction in racial/ethnic disparities.
8 EmblemHealth Neighborhood Care A Unique and Special Kind of Care Program Components Multidisciplinary Team at the Community Level EmblemHealth Neighborhood Care is a warm and inviting place where all members of the community can come in and meet face-to-face with EmblemHealth professionals to ask questions, get reliable information and solve problems. In addition, a multidisciplinary clinical support team is available to help EmblemHealth members and residents learn how to take better care of their health and provide health guidance, medication and counseling. The first two EmblemHealth Neighborhood Care locations are open in Harlem, New York and Cambria Heights, Queens. These locations were chosen because of the large African- American/Black and Hispanic populations, high-rate of disparities in many quality indicators, and the disproportionately high-rate of chronic disease such as diabetes and hypertension. improvement, and implementation of clinical and community-based programs to test various culturally competent communication strategies. The sessions will aid organizations seeking to develop evidence-based practices, promote higher standards of care, and support consumers health and health care. Workforce To meet the needs of the communities we serve, the multidisciplinary team: Is connected to the community personally and understands the community needs and resources. Speaks the language that reflects the community that the team serves. Receives training on communication and cultural competency. Cultural Competency Training EmblemHealth s robust culturally competent training program fosters an understanding of contextual factors that place individuals and their families at risk for poor health and health disparities. The core curriculum includes a broad-based foundation on cultural competency, communication, listening and negotiating skills, all aimed to mitigate the communication barrier between patient and staff. In addition, community-specific modules have been developed and tailored in recognition of the unique cultural diversity across and within population sub-groups. The plan will highlight training programs, institutional efforts to address quality Core Module: Cultural Competency I * (1) Core Module: Cultural Competency II Subgroup-specific & Community-level data, Cultural Influences & Understanding Case Studies and Vignettes Supplemental Module: Health Care Systems (2) Health, Public Health, and Healthcare Immigrant Access to Healthcare Supplemental Module: Communication (3) Non-Violent & Compassionate Communication Making Observations Conversation Blockers & Helpers Identifying & Expressing Feelings & Needs; Positive Action Statements Making Suggestions Not Demands, I Statements Interviewing, Home Visiting, Information Gathering, and Documentation Non-Verbal Communication Online training utilizing Quality Interactions for Nurses & Case Managers and Quality Interactions for Health Care Employees In-person training include subgroupspecific data, cultural influences and case studies and vignettes. The subgroups referenced for the pilot is Harlem and Cambria Heights, New York. Supplemental Module on Healthcare System, Access and Resources Supplemental Module on Effective Communication Sister Talk An example of the types of programs that Emblem Health aims to implement at Neighborhood Care is Sister Talk. The goal is to deliver, at the level of the community at large, health programs that are specific and tailored to the needs of the community. Sister Talk Hartford (STH), a faithbased healthy lifestyle-weight loss program, funded by the Donaghue Foundation, was developed and tested collaboratively by researchers, hospital leaders and the leadership and volunteers of 12 African American Churches in Hartford. The 12-week group support program is delivered in the church by trained church volunteers. It is a blend of spiritual and scientific weight loss guidance delivered in film and manualized with small group-leader materials. Hartford church leaders translated key weight loss principles into motivational faith-based sermons, prayers and messages and are featured in the STH films along with culturally appropriate and guideline-driven weight loss advice. Working with our partners at The Ethel Donaghue Center for Translating Research into Practice Policy (the TRIPP Center) at the University of Connecticut Health Center, we are in the process of translating STH for delivery in Harlem and Cambria Heights with a grant from the Donaghue Foundation. The proposed project aims to address barriers to dissemination of health promotion programming and will result in a promising dissemination plan with a corporate sponsor, a retranslated STH, with the partnership and the tools to carry out planned dissemination in the Harlem and Cambria Heights neighborhoods in New York City. Specific Aims Develop a dissemination plan for STH that coalesces the separate but overlapping missions of the public health researcher, EmblemHealth and the church. Identify key elements of the STH innovation that require rebranding and translation to meet the unique and common motivations, expectations, and support needs of two similar yet unique target neighborhoods. Rebrand, re-message, pilot and package Sister Talk for dissemination in New York City target neighborhoods. NEIGHBORHOOD CARE
9 30% Well Visit Jan-June 2011 among Year Old Black & Hispanic Members with No Visit in Prior Year Percent with Visit 25% 20% 15% 10% 5% 23.9% 19.4% 0% Intervention Group Control Group 100% Well Baby Visits (0-15 Months) by Race/Ethnicity and Year % with 6 Well Visits 90% 80% 70% 60% 2011 National 90 th percentile 88.5% 50% Asian 87.4% 83.3% 86.4% 91.4% 93.8% Black 62.2% 74.7% 81.9% 87.2% 92.0% Hispanic 78.3% 73.9% 84.2% 91.0% 88.5% White 88.0% 89.2% 90.6% 93.8% 93.8% Performance Year Adolescent (12-21 Years) Well Visit by Race/Ethnicity and Year 100% 90% % with Visit 80% 70% 60% 50% Asian 64.2% 67.6% 72.5% 74.3% 73.0% Black 54.6% 62.6% 67.4% 68.5% 68.0% Hispanic 60.2% 57.2% 65.3% 67.5% 69.9% White 67.8% 68.7% 71.7% 71.5% 73.2% Performance Year 30% Well Visit Racial/Ethnic Disparity Gaps 1 Over Time Percentage Point Gap 25% 20% 15% 10% 5% 0% Months Old 25.8% 15.3% 8.7% 6.5% 5.3% 3-6 Year olds 13.7% 12.4% 9.0% 8.4% 7.5% Year Olds 13.2% 11.6% 7.2% 6.7% 5.1%
10 HealthPartners The EBAN Experience: An Equitable Health Collaborative An Equitable Health Collaborative Reduce Disparity and Transform Care Delivery The EBAN Experience is an innovative, large-scale initiative involving community members and health care professionals working together on teams to improve patient care and community health. It decreases health disparities of minority populations through experiential learning, community dialogue, and health care systems improvement. In 2012, teams from HealthPartners health system completed the one-year-long experience. Analysis of the pre- and post-survey results indicates that EBAN participants breadth and depth of understanding about cultural differences and I learned the importance of building trust and relationships with patients and communities. We need to take time to build relationships with communities before jumping to solutions. Mammography Team Member A Unique Experience Health professionals and community members come together to solve problems Long duration, extended learning format Structural changes in clinical system design to improve care Build partnerships with communities Platform for continued engagement with communities on health equity and social determinants of health theater to raise awareness Screenplays written by playwrights native to the culture Professional directors and actors (Mixed Blood tpt television of the effect of culture on health Clinical Improvement Opportunity Team Action Clinical Outcome Increase pediatric immunization rates Documented list of reasons why immunizations Increased awareness of barriers and concerns; for children from East Africa. were refused; engaged with community using nurse referrals to prompt patients to schedule vaccine safety and timing; return visits. Trained staff on communication methods; Improve diabetes health outcomes Conducted interpreter-staffed small and large group 83% of participants who had baseline HbA1c 8% showed through education for Ethiopian patients. a decrease of at least 0.3% within 6 months. healthy eating and followed up with targeted 80% of participants who had baseline HbA1c < 8% remained in case management. Utilized storytelling and control within 6 months. Increase colorectal cancer screening Determined cultural and knowledge barriers. Increased percentages of colorectal cancer screening in patients rates for communities of color. Dispelled misinformation and offered an alternate of color from 45.7% to 55.7%. test that was culturally more acceptable. Trained staff on new types of tests/procedures. Decrease readmission rates for Held an open house to build relationships Established a direct phone line for readmission information. minority and limited English with community clinics with the hope of Begun conversations work to continue. improving communication about transitions of care to reduce hospital readmissions. Improve pain medication delivery time Communicated with ER physicians and produced The overall percentage of patients who received analgesia for minority and limited English FACES pain scale cards to be distributed to increased and the initial disparities were essentially eliminated. adult patients to improve the way staff determine Increased the capture of race data from 72.5% to 95.4% in ER. room (ER). pain level of patient. Educated clerks to better capture race information. Increase colorectal cancer screening Asked community members to provide feedback on Staff gained greater awareness of patient preferences. rates for Hmong and Somali patients. colonoscopy procedure from their cultural Outreach reminder calls, with the assistance of interpreters, perspective. Outreach calls made to overdue improved screening rates. patients. Requested more interpreter assistance to Process changes are being developed, utilizing recommendations reach non-english speaking patients. from community advisors, to prepare patients for a colonoscopy. Intent to conduct more community outreach using cultural ambassadors to educate the communities on new types of colorectal cancer screening. Increase breast cancer screening rates Learned that Hmong community needs more information on for Hmong and East African patients. events. Listened to attendees to understand barriers. mammography screening, that Hmong radio stations should be used to spread messages, and that we should target adult children Increase rates of advance directives for Intentionally used QI techniques and tools to Improved the rate of Advance Directives in the MSHO African American members. provide structure. Diverse team and community African-American population from 25% to 32% completion rate. Narrowed the disparity gap between Whites and and messaging needed. African-Americans from 25% to 21%. Met goal of 15% improvement rate of pediatric varnish application rates for children from publically be applied at recall visits and due to the success of for publically insured patients. insured families. pilot, plan spread to three additional clinics. EBAN is one of the traditional symbols of the Asante people of Ghana and represents safety, security, and trust. The EBAN Experience : An Equitable Health Collaborative is a collaboration of HealthPartners Institute for Education and Research, Mixed Blood Theatre, Twin Cities Public Television and community members. This collaboration is sponsored in-part by an educational grant from Pfizer Medical Educationn Group. For more information contact Debra Bryan, MEd, or visit EBANexperience.com HealthPartners
11 Highmark The Collection of Race, Ethnicity and Language Data: Why Collect Race, Ethnicity and Language Data? We can t help our members impacted by health care disparities if we don t know who they are. What is the benefit to our members? We can Identify care gaps We can develop cultural and linguistically sensitive care programs and interventions We can customize and tailor our educational outreach We can engage members in their health and wellness and this will eventually lead to improved health outcomes. Results As of 8/31/12, we have direct data on 18.2% of members for race, 7.9% for ethnicity and 9.4% for language spoken at home. Overall, we have all three pieces of data on 6.6% of current membership. Campaign 2009 member mailing paper survey Mail quantity Completions Response Rate 302, , % 2011 member direct mail 161,943 16, % 2011 employee 11,495 3, % 2012 member direct mail 232,972 37, % Best practices In May 2011, Highmark received Distinction in Multicultural Health Care (MCH) by the National Committee for Quality Assurance (NCQA). This award exemplifies the company s leadership in working to improve health care for all Americans, and specifically recognizes Highmark s Commercial HMO and Medicare Advantage HMO products offered under the Keystone Health Plan West subsidiary. Highmark was recognized for designating health care disparities reduction as a strategic goal; successfully collecting and analyzing race, ethnicity and language data; and implementing interventions to address heart disease and diabetes among African- American members. Recommendations MISSON: HEALTH EQUITY AND QUALITY SERVICES Our mission is to lead Highmark in achieving health equity for our members through targeted programs that improve health and wellness. Our vision is for equitable and quality health care for all. Elements of the program We have a dedicated team of health care professionals and our health equity program is part of Highmark s Quality Program and subject to all of the quality, accreditation and compliance processes. Our program is very comprehensive and has taken years to build. Health plans in the early phases of developing their health equity programs should stay encouraged. Key areas to focus are on the collection and utilization of race, ethnicity and language data. Aligning our efforts within a quality improvement framework has been the key to our success, along with strong senior management support. HIGHMARK.COM
12 Humana and the National Council of LaRaza (NCLR) Viviendo Saludable The Hispanic Senior Diabetes Pilot Program Description Phase One: In a joint effort to improve the health of Hispanic seniors with type 2 diabetes, Humana (NYSE: HUM) and the National Council of La Raza (NCLR) launched a study in 2011 to test the promotores de salud or, community health worker approach to help this patient population better manage their disease and improve their health and well-being. This project tested a promotores-driven approach to diabetes management and self-care among 100 Hispanic seniors with type-2 diabetes who are members of the Mexican American Unity Council (MAUC), a community-based organization and NCLR affiliate in San Antonio, TX. Phase Two: The National Council of La Raza (NCLR) and Humana are currently launching Phase II of a one-year study to test the promotores -driven approach to diabetes management and self-care among approximately 150 Hispanic seniors with Type 2 Diabetes who are Humana Medicare Advantage members and current or potential members of the Mexican American Unity Council (MAUC), a communitybased organization and NCLR affiliate that is helping to implement the study in the test market of San Antonio. Findings Initial results from Phase One indicate positive changes in diabetes self-management behaviors as well as diabetes health outcomes measures. The combination of promotores de salud and a culturally tailored diabetes self-management approach has yielded health improvements for participants. The peer support provided by promotores appear to be a key component in participants change in behavior. Best Practices Through this community healthcare worker and culturally tailored intervention, Phase One participants learned how to: Incorporate nutritional management and physical activity into their lifestyles; Use medications safely and for maximum therapeutic effectiveness; Monitor and interpret blood glucose and other measures to enable self-management decision making; Prevent, detect and treat acute and chronic complications; Develop strategies to address psychosocial issues and concerns; and Develop strategies to promote health and behavior changes. Lessons Learned Phase One: It was a challenge for the MAUC to recruit Humana participants for Phase One of this study. There were several challenges that we had not anticipated that did not enable us to recruit Humana participants for this first phase. These challenges were: 1. Member transportation issues to access program 2. Due to members unfounded fear that participation in program may affect future benefits with health plan 3. Lack of support from member providers due to lack of awareness of the program Phase Two: For Phase Two, we have enlisted the help of our providers in participant recruitment. We are also educating our provider partners regarding the diabetes self-management program prior to starting recruitment. Recommendations Based on initial results, it appears that using a combination of community healthcare workers and a culturally tailored diabetes self-management program are effective tools for improving Hispanic diabetic seniors health outcomes. It is still too early to tell whether our revised recruitment approach will be effective in increasing participation. Please note that the sample size for both phases is small and can only be used as directional indicators of behavior change.
13 Kaiser Permanente National Linguistic & Cultural Programs Clinician Cultural and Linguistic Assessment and Language Concordance Program PROGRAM OVERVIEW Patient clinician language concordance is a critical component of the language access equation and is considered the gold standard for communication. As a result of lack of validated testing standards, measures, and tools, Kaiser Permanente National Linguistic & Cultural Programs (NLCP), National Diversity developed the Clinician Cultural and Linguistic Assessment (CCLA) Initiative to ensure verifiable linguistic proficiency in clinical encounters and has established a standard level whereby the clinician is deemed to have a qualifying level of proficiency in communicating directly with patients independent of an interpreter. Our benchmarking efforts in language concordance have been rooted with the key aim to identify talented bilingual and bicultural clinician workforce and to establish the systems foundation to coordinate appropriate language services. PROGRAM HIGHLIGHTS The Kaiser Permanente Clinician Cultural and Linguistic Assessment (CCLA) tool serves as a foundation to the Kaiser Permanente Language Concordance Program, and many organizations are using the tool to objectively measure the communicative competency of their physicians, who have selfreported fluency in a language other than English. The CCLA tool is available in 20 languages. Amharic Cantonese Japanese Russian Arabic Farsi Korean Spanish Armenian French Mandarin Spanish (version 2) Burmese Hindi Polish Tagalog Cambodian Hmong Portuguese Vietnamese Kaiser Permanente has licensed the CCLA tool to a third party test administrator to allow any organization domestic and international to benefit from its use. To enhance testing administration, the use of Interactive Voice Response (IVR) technology is leveraged to administer the KP-CCLA over the telephone with availability 24 hours per day, 7 days a week. To date, the CCLA tool has been disseminated in various organizations in 15 states across the country: Children s hospitals City and county public hospital Community clinics County public health department Health care network Health plans Mental health departments Regional academic healthcare systems Schools of medicine State primary care medical society University academic medical centers Faith-based hospitals More than 1,300 Clinician Cultural and Linguistic Assessments have been administered to physicians (representing primary care and specialties) across the nation. BEST PRACTICES Leveraging the CCLA, Kaiser Permanente has developed language concordance strategies and interventions, such as 1.) appointment matching by language, 2.) hiring strategies for bilingual staff and providers, 3.) incentive programs for bilingual skills, 4.) monitoring and evaluation of language concordant services, 5.) training and educational development for providers, and 6.) upstream approaches to inform pipelines in medical education. As part of its internal dissemination efforts in Kaiser Permanente, National Linguistic & Cultural Programs, National Diversity has garnered buy-in from senior and medical leadership in the organization, identified physician and administrator champions, and provides foundational and on-going consultation and technical assistance. Additionally, NLCP provides consultation and technical assistance to the broader health care community. RECOMMENDATIONS To ensure a successful adoption of the Clinician Cultural and Linguistic Assessment and for the development of a Language Concordance Program, the following are key elements: 1. Garner buy-in at all levels of the organization, including physicians. 2. Establish a point of contact to coordinate assessment administration and the delivery of assessment results. 3. Identify incentives to encourage completion of the assessment as well as those who passed the assessment, such as differential pay, lump sum bonus, educational opportunities, etc. 4. Increase awareness of the importance of qualified bilingual skills in ensuring patient safety, promoting quality, and achieving equitable health outcomes throughout the organization. 5. Create a culturally competent system in having the right mix of people, technology, policy and accountability that supports and enhances the skills of the qualified bilingual clinician, preventing burn-out and promoting morale. 6. Contact NLCP, National Diversity, Kaiser Permanente for more information. Gayle Tang, MSN, RN, Senior Director,
14 Molina Healthcare of California Language Access for Chaldeans in San Diego County, CA Program Description Best Practices Molina Healthcare of California received an influx of Chaldean Members in San Diego County. Chaldeans are people from the Middle East, primarily from Iraq who speak Arabic and are Christian. This project was conducted to address the linguistic needs of the Chaldean population. This process ensures that members are matched appropriately to doctors when they do not select a doctor that speaks their language or are assigned to a doctor by the autoassignment algorithm. This strategy improves quality of care for patients and decreases interpretation costs. We collaborated with our Provider Services, Enrollment Operations and Member Services Departments. Due to the high demand for faceto-face Arabic interpreters, Molina conducted geo-mapping. This approach was established to match Arabic speaking members with Arabic speaking providers within a mile radius of member s residence. Next Steps Member Services staff will follow up with the 54% of Arabic speaking members who did not respond via phone call or another letter Goal Explore hiring an Arabic interpreter requests to interpret during medical appointments Help control interpreter costs Assist Arabic speaking doctors to grow their patient panel Refer members with more than 3 interpreter per month to our Complex Case Management Department Ensure that the member s physician understands their cultural beliefs Explore video remote interpreting as an alternative solution for delivering interpreter services in provider offices. Increase quality of care for members Methodology As of May 2012, Molina had 4,293 Arabic speaking members in San Diego County, with the majority residing in the town of El Cajon. We have 22 Primary Care Physicians in 15 different locations that speak Arabic. Molina mailed out 1,374 letters to Arabic speaking members who are not currently assigned to Arabic speaking providers in San Diego County. This letter informed members of the following: There are Arabic/Chaldean speaking doctors near their home These doctors are happy to accept them as their patient Recipients either responded by mail or phone if they wanted to switch to an Arabic speaking doctor. Coordinating Organization: America s Health Insurance Plans
15 Neighborhood Health Plan Massachusetts Improving Diabetes and Blood Pressure Management for Black/African Americans in the Boston Area Program Description Neighborhood Health Plan (NHP) identified a disparity among our Black/African American members who were diagnosed with diabetes and hypertension (as measured by HEDIS ) compared to their White counterparts. We identified that the inequity was most prevalent in the communities of Roxbury, Dorchester and Mattapan, the predominant communities of color in the Metro Boston area. After securing feedback from our focus group, we launched a community based educational campaign targeting the impacted neighborhoods and population at risk. Program Highlights Deployed culturally sensitive educational messages within the community (bus kings, bus shelters, train cards, neighborhood media advertorials) Feet on the Streets Conducted an educational food shopping experience at a targeted supermarket in partnership with the American Heart Association. Disease experts from NHP s Diabetes program as well as Diabetes Educators from local Community Health Centers on hand for member specific questions. Collaborated with contracted DME vendors (blood glucose monitoring, blood pressure monitoring) to hold a health clinic at a targeted pharmacy in our network. Promoted the use of a local farmer s market by including a discount coupon to attend one of the educational sessions. Leveraged a health promotional activity at a local Community Health Center to connect and engage the target population with care providers. Barriers Production and media buy schedule determined when the campaign was launched. This approach precluded a check in with our focus group. Lessons Learned/Best Practices (based on observation; measured results pending) It is essential to work with the population you are trying to influence as you design interventions during all phases of the journey. Health Plans can play an important role in facilitating the networking among well-intended but disparate community based organizations and providers. Leveraging existing relationships is an untapped opportunity (e.g. DME vendors) We need to recognize that only 10 percent of health care occurs in a doctor s office; bringing health education messages into the community to promote self care is essential. These efforts are public health promotions. Plans need to put competition aside to improve equity performance for the diverse communities we serve.
16 ODS Equity Compass 360 : Setting the Course for Equality and Diversity in Healthcare The right care, at the right time, in the right place, ODS is working to improve health equity from the inside out. Our mission is to eliminate health disparities in order to provide the highest quality of care to all ODS members and the communities we serve. at the right price. Our strategic plan includes five key initiatives: 1. Increase education and awareness 2. Improve understanding of member population 3. Develop standards for plain language and cultural competency 4. Implement staff cultural competency training 5. Incentivize providers toward CLAS best practices Internal presentations, increased attendance at diversity events, increased involvement in local health equity efforts Developing data collection processes; working with state (Oregon) to clean up data Implemented a Cultural Competency and Plain Language policy for all consumer materials developed by our organization Early stages of developing staff training requirements Best Practices and Lessons Learned This project is an ongoing learning experience, but there are two specific take-aways that we feel contributed to the success of our project. 1. Find complementing priorities: We identified other priorities in the company that could be integrated with our health equity efforts. This created a driving force behind the health equity initiative 2. Engage stakeholders early and understand their needs: We involved internal stakeholders early in the development process and encouraged them to work with us in identifying how health equity could help them and meet their needs. Conclusions/Recommendations In addition to the lessons learned, we found it important to be realistic and be flexible. Remind yourself that there is a process to creating successful and sustainable change, and set realistic goals to achieve that change. Also, be flexible. Doors will open and close, but remember to go with the flow and take advantage of every opportunity that presents itself. It is important to keep driving the initiatives forward through whatever avenue is available. We listen more than we talk. We lead more than we follow. We do the right thing. All ways. Always.
17 UnitedHealth Group Health Equity Services Program: Strategy & Description Program Overview Program Design UnitedHealth Group (UHG) has supported efforts to reduce health disparities for over a decade. In 2012, we fortified our commitment to this effort by founding the Health Equity Services Program. This cross-functional, cross-business program includes leaders from our clinical, network, operations, data and informatics, customer service and marketing departments to foster a holistic approach in achieving our goals. The program mission directly aligns with the UnitedHealth Group mission: Helping People Live Healthier Lives. Enterprise Wide Pillars of Promoting Health Equity Mission Promote health equity by developing methods and services to identify and focus on multicultural populations, increase understanding of diverse health care needs, improve patient-centered capabilities, and enhance member health outcomes. Infrastructure: Data & Tools Goals Reduce health disparities to improve the quality of health of consumers and communities. Embrace diversity by creating a continuum of culturally sensitive initiatives that promote health and prevent avoidable health care cost. Objectives 1. Improve member health and health equity by improving access, activation, appropriateness, and affordability of clinical programs and information. At the foundation of the Health Equity Services program, is the Data Collection and Tools Enhancement team. This area is working to further develop the necessary tools that enable the collection, storage, analysis and availability of race, ethnicity and language information. Such information supports the continued enhancement of culturally sensitive clinical programs that minimize health disparities and improves our ability to provide access to culturally and linguistically appropriate services. Our priorities include enhancing our current analytics infrastructure to stream race, ethnicity and language data directly reported from the consumer, through our various analytical tools, to the businesses, where the information can be integrated into clinical, marketing and service strategies to provide a more customized and effective outreach to our members. 2. Drive growth of demonstrable value to diverse populations. 3. Position UHG as a socially responsible and innovative market leader. 4. Establish multicultural programs and capabilities as UHG core competencies. 5. Enhance community engagement and outreach to support positive behavioral change. 6. Institute key diversity metrics, data collection methods, and reporting tools to monitor and enhance clinical programs and innovations. 7. Create tools that will further improve our member-centric capabilities Coordinating Organization: America s Health Insurance Plans
18 WellPoint Medical Consumerism Online Training for Health Educators Program Description WellPoint developed an online training course to support outreach efforts of communitybased health educators with teaching and facilitation tools to cover topics such as: Effective Medical Communication Both Parties Need Skills Navigating the U.S. health care systems, Effective health communication skills with providers, How to seek bilingual health information, and Background Minority communities as a whole have had greater difficulty with the American health care system than others. Research has shown that successful programs to close the gap in chronic diseaserelated health disparities in various racial and ethnic populations are built on strengthening the links between health care providers and their patients (Roe & Thomas 2002). Finding a lack of resources that teach minority patients health care communication and medical consumerism skills, WellPoint worked with community health worker organizations and experts in medical cross-cultural communications to develop this resource to teach the general medical consumer tips on the U.S. health care systems, effective health communication skills with providers, how to seek bilingual health information, and patient rights. Patient rights within the U.S. health care system. Since the program s launch in March, 2011, we have trained and worked with community health worker groups in Arizona and Texas, as well as public health alliances in California and New York to implement and evaluate the training curriculum and tools. One Course Development Process recent evaluation of a pilot demonstration that ran from December 2011 March 2012 Lessons Learned and managed by Concilio Latino de Salud, While several evaluations of the course as Inc., a promotores organization in Phoenix, deployed to community health workers and Arizona, trained over 20 promotores using promotores were very positive, it was clear that the curriculum, who in turn used the patient replication of the course s patient education training materials to teach over 200 Hispanic materials proved to be a cost barrier to not-forpatients in Maricopa County. Over 90 patients profit organizations. who completed a follow-up survey three months after The primary lesson is that, while the idea of a live training by a receiving the initial training, 70 percent reported having health educator to patient is sound, such training may be more used what I learned to communicate with my doctor. efficiently delivered to the patient/medical consumer directly. More importantly, 73 percent reported that I was able Organizations that deployed the training did so primarily with grant to communicate better with my doctor, and 83 percent funding to print the materials, otherwise, the patient education reported sharing this information with my family and resources were not used. friends. The course is fully enabled in both English and Spanish, and is available, at no cost, to the general public at The training may be implemented for health educators working in a variety of organizational settings, including clinics, community-based organizations, advocacy organizations, hospitals, social services agencies, etc. Conclusion and Recommendations WellPoint is now in the process of adapting the training into a direct-to-patient version, and will explore forming a learning center in our online member portal with e-tutorials on medical consumerism skills, understanding health insurance benefits, how to use medical consumerism tools such as Zagat Health, etc. Course Components Making the Case Content & Handouts In Person Training Guide Coordinating Organization: America s Health Insurance Plans
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