ADDRESSING THE 80%: USING CULTURAL COMPETENCY AND HEALTH LITERACY TO MEET HEALTH-RELATED SOCIAL NEEDS Mingie Kang, MPH, Better Health for Northeast New York Jessica Chanese, BA, Adirondack Health Institute Elizabeth Campisi, PhD, Alliance for Better Health, LLC NYSPHA 2017 Annual Meeting and Conference April 27, 2017
Presentation Outline Overview of DSRIP program framework and three PPSs How Cultural Competency and Health Literacy (CCHL) fits in the overall program goal Relationship between CCHL and social determinants of health Each PPS s CCHL initiatives for partner collaboration and training to address social determinants of health The impact of CCHL efforts on population health goals Results of three PPSs collaboration efforts to date Q&A
What is DSRIP? Stands for Delivery System Reform Incentive Payment program Happening across the New York State $6 billion available as incentives over 5-year period Overall goal of reducing 25% of avoidable ED and inpatient visits by 2020
DSRIP Triple Aim
What are PPSs? Stands for Performing Provider System 25 PPSs across the New York State, all different in size and counties covered Network of various health care and social service providers, such as: Hospitals Clinics Mental health Substance abuse treatments Care management agencies Community-based organizations Collaboration is key for the State s overall success.
Adirondack Health Institute Covers 9 counties including Clinton, Essex, Franklin, Fulton, Hamilton, Saratoga, St. Lawrence, Warren and Washington 145,000 attributed Medicaid beneficiaries and uninsured members 114 partner organizations in network Unique facts about this PPS: Service area has a total population of approximately 700,000 spread over 11,000 square miles. Region is largely rural and encompasses part of the Adirondack Park
Better Health for Northeast New York Covers 5 counties including Albany, Columbia, Greene, Saratoga and Warren About 69,000 Medicaid beneficiaries and uninsured members attributed Over 175 community healthcare organizations in network Formerly known as Albany Medical Center Hospital (AMCH) PPS, has seven governing committees including Consumer & Community Affairs Committee
Alliance for Better Health, LLC Governed by 5 member organizations: St. Peter s Health Partners, Ellis Medicine, St. Mary s in Amsterdam, Whitney M. Young Health and Hometown Health Centers Covers 6 counties: Albany, Fulton, Montgomery, Rensselaer, Schenectady and Saratoga 193,000 attributed Medicaid beneficiaries and uninsured members More than 2,000 providers and CBOs in our network
What are Cultural Competency and Health Literacy? Definitions of Cultural Competency a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations. (Cross et al, 1989) the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients. (Betancourt et al, 2002) the ability of health care providers and organizations to understand and respond effectively to the cultural and language needs brought by the patient to the health care encounter. (Cross et al, 1998) Definition of Health Literacy the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (Nielson-Bohlman et al, 2004)
How does CCHL fit in DSRIP? Better care, Better health, Reduced cost Domain 2: System Transformation Domain 3: Clinical Improvement Domain 4: Population-wide Projects Domain 2, 3 & 4: Project Components Governance Financial Stability Cultural Competency & Health Literacy Workforce Strategy IT Systems & Processes Performance Reporting Practitioner Engagement Population Health Management Clinical Integration Domain 1: Organizational Components
The 80%: Social Determinants of Health Social determinants of health are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. According to the World Health Organization, roughly 80% of factors influencing health outcomes can be categorized as non-medical social determinants. 11
The Relationship Between Social Determinants of Health and Health Disparities Figure 2. World Health Organization's Social Determinants of Health Conceptual Framework [1] Health Disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. (CDC) Health inequities caused by social determinants lead to health disparities Health disparities are fundamentally related to social justice issues What are some of our region s disparities? 12
Social Determinants of Health in Rural Settings
Capital Region (Albany, Schenectady, Rensselaer, Saratoga) About 20% of households earned less than $25,000 annually. Percent of urban children living in poverty: Troy: 46.4% Schenectady: 41.9% Albany: 32.2% Saratoga Springs: 4.5%. Sources: Capital Region Statistical Report, 2015, Capital District Regional Planning Commission
Source: Capital Region Statistical Report 2015
Source: Capital Region Statistical Report 2015
Capital District (Albany, Schenectady, Rensselaer Counties) Asthma hospitalization rates for the Capital District are significantly higher or higher than New York statewide rates. African Americans had 4.4 times the asthma hospitalization rates of the region average African American have diabetes mortality rates twice as high as non-hispanics whites. Admissions for short-term diabetes complications in high need neighborhoods were 1.5-5.5 times the expected admission rates More social determinants More than 80% of minority communities are in areas with stores that don t sell low fat milk or high fiber bread. Sources: Healthy Capital District Initiative, Community Health Needs Assessment 2013; Albany Medical Center Community Health Needs Assessment 2013
Franklin County (Adirondacks) 63% of the county is considered rural Ranked 46 out of 62 New York counties overall in 2017 RWJF Health Outcome Rankings (61 in Health Factors and 62 in Health Behaviors) At 27%, the adult smoking rate is higher than the rest of the state (18%) 17% of the population is living at or below 100% FPL and 37% at or below 200% FPL, compared to the NY state rates of 15 % and 32% Ratios of population to clinical providers are 420:1 for mental health, 1510:1 for primary care, and 2,300:1 for dental. Age-adjusted death rates for diabetes, lung cancer, and colorectal cancer are higher than the state averages
Greene County In 2017, Greene County was ranked #53 among all New York counties (62) according to RWJF Health Outcome Rankings. Greene s adult smoking rate of 24.5% was higher than Rest of State (18.0%). Greene s mammography screening rates (67.6%) were lower the Rest of State (77.8%) for women 40 years of age and older. Greene County s poverty rate of 15.1% was the highest in the Capital Region. Greene s mortality rates due to heart attack, coronary heart disease and stroke were all higher than the Rest of State.
How Does CCHL Relate to Social Determinants of Health? Mitigates social barriers to accessing care and services Informs development of effective interventions, programs, and policies Example: ACEs (Adverse Childhood Experiences) as part of CCHL Economic Instability Access to health and social services Language Barriers Cultural Competency & Health Literacy Transportation Housing 21
How Does CCHL Relate to Health Disparities?. Poor health outcomes are linked to lack of culturally competent care and low health literacy skills. CCHL initiatives equip providers with tools and strategies to address individual and regional needs that can lead to health disparities. Therefore, PPSs CCHL efforts can reduce health disparities and promote health equity. 22
Key Components of Addressing Social Determinants of Health Through CCHL Understanding community needs and resources Leveraging expertise of community based organizations (CBOs) Training and education Cross-sector collaboration Promoting patient activation and selfadvocacy Valuing beneficiary input Source: Countyhealthrankings.org 23
Leveraging Community-Based Organizations in CCHL Initiatives Community-Based Organizations (CBOs) will Provide interventions to community members Assist with patient and provider education Assist with gathering beneficiary feedback/hosting community forums/listening sessions Function as subject matter experts and trainers in various PPS CCHL activities 24
Cultural Competency/Health Literacy Training Promotes provider self-awareness and commitment to change Helps clinicians understand their subconscious biases in shared decision making with patients Helps administrators recognize ways in which their clinics may deliver care that lead to worse instead of better outcomes for vulnerable patients While we aspire to create a non-threatening learning environment, discomfort may be necessary to convince some of the need for change. Source: Chin, Marshall H. MD, MPH. Movement Advocacy, Personal Relationships, and Ending Health Care Disparities. Journal of the National Medical Association, Vol 109, No 1, Spring 2017
How are PPSs Targeting Health Disparities through Training and Other CCHL Initiatives? Poverty awareness through Bridges Out of Poverty training pioneered through the Schenectady City Mission and Aha, Inc. One and two-day workshops that use a comprehensive approach to understanding poverty through the lens of economic class. Participants review poverty research, examine a theory of change, and analyze poverty through the prism of the hidden rules of class, resources, family structure, and language. Poverty/low SES identified as high priority driver is a significant driver of health disparities. Bridges provides concrete tools and strategies for a community to alleviate poverty. 26
How are PPSs Targeting Health Disparities through Training and Other CCHL Initiatives? Capital Region Health Literacy Symposium held on March 2017 Collaborative event between BHNNY and the Alliance 4-hour symposium presented by Michael Paasche-Orlow, MD, MA, MPH from Boston University School of Medicine Over 100 attendees from partner organizations affiliated with BHNNY and Alliance, along with AHI staff Health literacy-related topics covered: Health Disparities Chronic Disease Management Care Transitions Teach-Back Method 27
How are PPSs Targeting Health Disparities through Training and Other CCHL Initiatives? AHI PPS s Customized CCHL Training Series Each module with focus on specific health disparity priority groups Incorporating CBO presenters into training modules Using CCHL as a framework for addressing regional health disparities 28
How are PPSs Targeting Health Disparities through Training and Other CCHL Initiatives? BHNNY s CCHL Champion Activities Each contracted partner has designated CCHL Champion Quarterly meetings for educational sessions on various topics Act as change agents within partner organization bringing cultural shift 29
How are PPSs Targeting Health Disparities through Training and Other CCHL Initiatives? Alliance for Better Health ü Training strategy PPS-wide trainings, some dispersed some centralized Incorporates structural competency, CCHL training aimed at social determinants. See advancingcc.org for webinar series at UAlbany School of Public Health, but Alliance will deliver a pilot live training Online learning through Healthstreams learning management system. Targets issues challenging vulnerable populations ü Organizational cultural competency assessments aimed at healthcare disparities Our 2 FQHC partners have conducted assessments Produces training plans tailored to each organization s ü Listening sessions run by 9 CBOs 30
How Does CCHL Impact Population Health Goals? Bridges Out of Poverty assists with provider understanding, which can help reduce health care disparities Health literacy training helps providers develop communication skills that promote trust and patientcentered care Structural competency involves addressing social determinants from a cultural humility perspective CBOs and Community Health Workers (CHWs) CBOs are very familiar with the population and usually have earned its trust. CHWs are from the communities they serve and educate and coach in socially appropriate ways.
Overlapping geographic areas, provider base, and patient populations Similar social determinants and provider communication issues More efficient to work together to achieve health equity Why Collaborate?
Results of Three PPSs Collaboration Alliance helped expand the Schenectady City Mission s training capacity to offer Bridges training throughout its coverage area. Bridges Out of Poverty Training AHI trained PPS partner staff as trainers who will use Bridges constructs to strengthen mental health and substance abuse prevention programs across the PPS. BHNNY continues to provide training opportunities for PPS partners through the Schenectady City Mission. Health Literacy Symposium in March 2017 Sharing Best Practices 3-PPS Public Forums 33
Future Collaboration CCHL Champion joint training session: to be scheduled before Sept 2017 Develop action steps based on Consumer Listening Session feedback 3-PPS Public Forum to educate about DSRIP activities Potential seminars building on success of health literacy symposium currently analyzing comments from March 23 event Potential HealthStreams portal with courses available to all 3 PPSs Continue collaborating through Statewide CCHL Collaborative
Thank You! Questions? 35