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1 Designing Culturally Appropriate Tools to Reduce Disparities in Hypertension Control and Colorectal Cancer Screening in Diverse Populations March 11, 2013 Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Winston Wong, MD, MS Medical Director, Community Benefit Director, Disparities Improvement & Quality Initiatives Berny Gould, RN, MNA Senior Director, Quality Hospital Oversight Equitable Care

2 Today s Agenda Agenda 9:00 15: Introductions & Overview of the Day 9:15 30: Background 9:30 10: Developing Strategies for Improvement 10:00 30: Addressing Hypertension 10:30 45: Break 10:45 11:15: Addressing Colorectal Cancer Screening 11:15 45: Replicating Efforts 11:45 12:00: Wrap up 2

3 Learning Objectives Empower participants to develop culturally and patient centered toolkits to improve hypertension control and cancer screening in minority populations Describe and use strategies to increase trust with patients through culturally competent interactions and care 3

4 Our Heritage - Founded in 1945 Kaiser Permanente is made up of three separate but closely cooperating organizations: Kaiser Foundation Health Plan, Inc. Kaiser Foundation Hospitals The Permanente Medical Groups

5 Kaiser Permanente The nation s largest not-for-profit health plan, serving 9 million members, with headquarters in Oakland, CA. 36 Hospitals, 533 Medical Centers across 9 states and the District of Columbia 51.4% of KP s membership are people of color, compared to 35% of the nation More than 182,000 employees and nearly 16,600 physicians, and 46,866 nurses; 56% are persons of color

6 Our Strategy Community Benefit Making a Measurable Impact on the Health of the Communities We Serve Transforming Care Delivery Best Care for Everyone Solving for Affordability Improving Cost Structure Growing Membership Expanding Access to KP Care Implementing Infrastructure Realizing Value Enabling Performance Through People Being the Best Place to Work Collaboration & Alignment Working through Partnerships Drives our Equity Strategy

7 National Efforts and Interests to Achieve Equitable Care Align with Existing Internal Momentum and Strategies Federal infrastructure to support health disparities 25M eligible for exchanges or Medicaid expansion Public reporting of health plan demographics Affordable Care Act Health Care Environment National Health Disparities Collaborative - trade organization of insurers Other insurers focus on reducing disparities Efforts to address IOM s Quality Chasm Institute for Culturally Competent Care 10 Centers of Excellence focusing on culturally tailored care Qualified Bilingual Staff Model; Health Care Interpreter Network Kaiser Permanente Culturally Competent Care Efforts Kaiser Permanente Disparities measurement HEDIS 16 measurement for 6 OMB categories Medical center level measurement Ongoing disparities in hypertension control and colorectal cancer screening 7

8 Inequities in Health Percent of adults age 18+ with diagnosed diabetes Percent of adults age 18+ with hypertension Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance,

9 Inequities in Health Care Heart Failure Hospital Admissions (Adjusted rate per 100,000 population) Diabetes Hospital Admissions (Adjusted rate per 100,000 population) Pediatric Asthma Hospital Admissions (Adjusted rate per 100,000 population) Hispanic 466 Hispanic 296 Hispanic 135 Black 959 Black 551 Black 384 White 349 White 151 White 94 Rates are adjusted by age and gender using the total U.S. population for 2000 as the standard population.. Data: Healthcare Cost and Utilization Project, State Inpatient Databases (AHRQ 2010). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance,

10 Economic Burden of Health Disparities Between 2003 and 2006 the combined costs of health inequalities and premature death in the United States were $1.24 trillion. Eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion for the years Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asians, and Hispanics were excess costs due to health inequalities. Eliminating health inequalities for minorities would have reduced indirect costs associated with illness and premature death by more than one trillion dollars between 2003 and Source: The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. Thomas A. LaVeist, Ph.D., Darrell J. Gaskin, Ph.D.l Patrick Richard, Ph.D. September 2009

11 Striving for Health Equity KPPG endorses NDC recommendations Development of the GEMS Datamart with reported and imputed race/ethnicity for all KP members Modifications to KP HealthConnect to collect race, detailed ethnicity, and country of birth data National Diversity Council develops policy implementation infrastructure for Member Demographic Data Collection Initiated equitable care measurement: four HEDIS measures and Medicare members (African American and White), using race data from the Social Security Administration Expanded equitable care measurement: All members and 16 HEDIS measures, using race/ethnicity data from the GEMS Datamart Quarterly updates of equitable care analyses available on the Big Q Dashboard; analyzed 21 TJC measures (AMI, heart failure, pneumonia, and surgical care) by race/ethnicity for KFH hospitals; special analyses for regional quality leaders 2011 March Equitable Care Health Outcomes (ECHO) Initiative developed; Leadership Alignment: Institute for Culturally Competent Care and Health Disparities Workgroup present data Baseline facilityor medical centerlevel equitable care reports were produced for every region July October 2012 National Quality Committee: Focus efforts on reducing disparities in Hypertension Control among African Americans and Colorectal Cancer Screening among Hispanics Equity Summit: Seeded a commitment to reduce disparities in focus areas; brainstormed goals to evaluate success in reducing disparities; shared existing strategies and connected work and people Agree on goals (program and region) to measure success in Hypertension Control and Colorectal Cancer Screening; identify opportunities to share and grow improvement strategies 11

12 2012 Included New Analytical Measures and Increased Engagement from Clinical Groups Jan March April June Agreement from regional quality leaders to commit to reducing gaps in HTN & CRC Ohio video ethnography: African American patient perspectives in improving HTN control ECHO Collaborative: Best Practices shared across quality leaders, commit to meet in the future Monthly HTN and CRC collaborative calls occur. Participation from X # regional physician, quality and diversity leaders July October November Dec Colorectal cancer screening videos (FIT kit & FOBT) developed New measurement available language, age, gender (since Dec 11), neighborhood income, and education Equity Summit 2: Featured patient perspectives to improve CRC and HTN Highlighted experiences with community based interventions Re-commitment of goals Shared best practices and how to develop internal commitments at IHI National Forum 12

13 Obtain Race/Ethnicity Data Self-identified race/ethnicity (RE) is the gold standard Data collection is supported by the KP HealthConnect Build, implemented in April 2009 Race: Black or African American; Hispanic or Latino; Asian; Native Hawaiian or Other Pacific Islander; American Indian or Alaska Native; and White Ethnicity: 268 specific granular ethnicities KP Members with Race or Ethnicity Data in KPHC 80% 73% 60% 40% 31% 39% 47% 20% 0%

14 The Equitable Care Dashboard: The HEDIS 16 Measures Cardiovascular Care Patients with cardiovascular conditions: LDL-C screening Patients with cardiovascular conditions: LDL-C control (< 100 mg/dl) Controlling high blood pressure * Persistence of beta-blocker treatment after a heart attack Prevention and Screening Breast cancer screening Cervical cancer screening Colorectal cancer screening Diabetes Care HbA1c testing HbA1c control < 9.0% HbA1c control < 7.0% Eye exam (retinal) performed LDL-C screening LDL-C control (< 100 mg/dl) Medical attention for nephropathy Blood pressure control < 130/80 mm Hg Blood pressure control < 140/90 mm Hg

15 Example: KP s Current Capacity to Measure Disparities 15

16 Disparities by R/E are Larger than Disparities by Income or Education 16

17 Rates by Income vary by Less than 3 Percentage Points 17

18 Disparities by R/E are Larger than Disparities by Income or Education 18

19 Disparities by Household Income were Negligible 19

20 Disparities by Education were also Small 20

21 New Analysis by Language, Age and Gender 21

22 Fundamental Components of Healthcare Disparities Interventions Physician Patient interactions Health literacy Cultural competence Language Patient and physician trust Utilization of Evidence Based Clinical Guidelines Customized Care Delivery Outreach Supporting patient decision making, including education, co-pays Community Engagement and Involvement Leverage community assets and trusted sources 22

23 Addressing Disparities Across a Gradient of Interventions Level 1 Single measurable event Patient commitment either opt out or opt in Examples: Screening measures; pnuemococcal vaccines for adults Level 2 Outcomes achieved over sustained clinical exposures with multiple patient touches Patient engagement intermediate to high Examples: Hgb A1c levels; hypertension control; lipid control Level 3 Highly dependent on impacting social determinants of health with early interventions & multiple community stakeholders Long periods of engagement with community and patients Examples: low birth weight infants (infant mortality); HIV prevalence; Obesity reduction

24 Improving Hypertension Control and Equity Joseph Young, MD The Permanente Medical Group Clinical Hypertension Lead 24

25 Developing the Tools to Improve Hypertension Control Change package (2) Webinars to identify regional activities to improve hypertension and colorectal cancer screening Engagement of clinical practice leads on both topics Development of driver diagrams and strategies to address the challenge Improvement plan Engaged DCSQ Performance Improvement group to lead this effort Developed the framework to identify processes necessary to implement projects Leadership Engagement Discussion of the resources need to advance the work Discussion of the most appropriate way to communicate this work both internally and externally Equity Summit Brainstorming and development of program wide goals to reduce the disparities gap in Hypertension and Colorectal Cancer Screening Action plan to finalize goals, engage and connect various stakeholders across the program to identify and spread existing clinical best practices

26 Hypertension & Colorectal Cancer Screening Goals Controlling High Blood Pressure Goal for 2012: Reduce baseline disparity between Black or African American and White rates by 25% by Dec. 31, Goal for 2013: Reduce baseline disparity between Black or African American and White rates by 50% by Dec. 31, Colorectal Cancer Screening Goal for 2012: Reduce baseline disparity between Hispanic and White rates by 25% by Dec. 31, Goal for 2013: Reduce baseline disparity between Hispanic and White rates by 50% by Dec. 31, Why these? Alignment with national priorities of National Quality Committee Mortality and morbidity burden on targeted groups

27 Improving Hypertension Control Among African Americans Challenge Improve Hypertension Control among African Americans Clinical Management Goals Appropriate Medication/ Appropriate Dose (National HTN algorithm) Follow Up & Monitoring Medication Adherence Lifestyle Modification KP National Hypertension Guideline: Link Hypertension/ Disparities Literature Leverage Points (potential indicators) Failure to Intensify Therapy* Patient- Clinician Relationship (duration/ frequency of relationship, patient satisfaction)* Health Care Access (nonattendance at scheduled visits, nonadherence to medicines/ labs)* Patient Knowledge Patient Diet/Exercise Patient Supports/ Resources Targets for Disparities Reduction Cultural Competency Decision Support Services Trust Building & Continuity of Care Accessibility of Information (language, literacy, context) Patient Cost Burden Ease of Access to Care Patient Education & Self-efficacy Patient Lifestyle Support (stress reduction) Community Education & Outreach *Available from existing KP data sources Proposed Disparities Reduction Strategies (examples) Clinic-Level Education/Feedback Centralized Population Care Health Connect Reminders (consolidate Rx/combo Rx/dose) Provider-Level Education/ Feedback New Patient Outreach calls Culturally & Linguistically Appropriate Education & Case Management Barriers Assessment (motivational interviewing) Tech Based Self- Management Support (cell phones, internet) Referrals for Health System Specialty Services/Classes Family-Based Interventions (cooking classes, salt education) Partner with Community Providers and Organizations (barber shops, churches)

28 Evidence Based Guidelines Hypertension Control 28

29 Improving Colorectal Cancer Screening Among Hispanics Challenge Prevention Goal Leverage Points (potential indicators) Targets for Disparities Reduction Specific Disparities Reduction Strategies (examples) Improve Colorectal Cancer Screening among Hispanics¹ Screening Options for Average-Risk Adults* High-sensitivity guaiac fecal occult blood test (gfobt) every 1 2 years. Immunochemical fecal occult blood test (ifobt/fit) every 1 2 years. Flexible sigmoidoscopy at least every 10 years. Colonoscopy every 10 years. A combination of highsensitivity gfobt every 1 2 years and flexible sigmoidoscopy every 10 years. A combination of ifobt/fit every 1 2 years and flexible sigmoidoscopy every 10 years. Lack of Patient Engagement (no visits, no internet use) Failure to Respond (contact, but no test on record Failure to Follow Up (positive test no record, no follow up Failure to Test (no test on record, late stage diagnosis) Access Barriers (location, schedule, transit, language, health literacy) Cultural and Linguistic Accessibility (knowledge of options, preferences for screening, perspectives) Real-Time Data for Clinical Staff (screening info available at time of any clinical encounter) Patient Knowledge/Beliefs/ Cultural Norms Assessment of Patient Barriers (solicit preferences/beliefs, customize screening options) Culturally & Linguistically Appropriate Outreach and Education (e-telenovelas, community based classes, one on one training through promatoras/community health workers ) Clinical Staff Recommendation/ Re-enforcement (Health Connect prompts during check in for any visit) Partner with Community Providers and Organizations (barber shops, churches) KP National Colorectal Cancer Screening Guideline: Link Colorectal Cancer Screening/Disparities Literature *Choice of test may be subject to regional and practice-level variation & may be related to patient screening rates.

30 Evidence based guidelines: Colorectal Cancer Screening Screening Options for Average-Risk Adults* High-sensitivity guaiac fecal occult blood test (gfobt) every 1 2 years. Immunochemical fecal occult blood test (ifobt/fit) every 1 2 years. Flexible sigmoidoscopy at least every 10 years. Colonoscopy every 10 years. A combination of high-sensitivity gfobt every 1 2 years and flexible sigmoidoscopy every 10 years. A combination of ifobt/fit every 1 2 years and flexible sigmoidoscopy every 10 years. 30

31 System Opportunities to Target for Disparities Reduction Access Barriers Location Schedules Transit Language Health literacy Cultural & linguistic accessibility Knowledge of options Preferences for screening Perspectives Real time data For clinical staff Screening information available at all clinical encounters Patient Beliefs, knowledge, norms, customs 31

32 Identifying the Steps to Address Disparities What do you need to improve? What do you have available to you? Where? Identify the challenge Set clinical management goals Identify leverage points Define Success Set Targets Replicate & Repeat Propose Strategies 32

33 Questions? Winston F Wong, MD, MS Medical Director, Community Benefit Director, Health Disparities Quality Initiatives Winston.F.Wong@kp.org Berny Gould RN, MNA Senior Director, Quality, Hospital Oversight, and Equitable Care Berny.Gould@kp.org 33