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Best Practices to Reduce Disparities

The Best Practices to Reduce Disparities are the essential elements of any successful disparities intervention.

The Road Map to Reduce Disparities is a comprehensive guide for organizations interested in reducing disparities: it outlines a systematic process to design, plan, and implement a disparities intervention.

But we know a systematic process is, indeed, systematic. And it’s important to understand the highlights, too. So as we look across this Road Map, what are the essential elements? What are the key ingredients for a successful intervention that you cannot miss?

Finding Answers has developed seven Best Practices to Reduce Disparities. Many of these are described in detail throughout the Road Map. Here, we summarize each of these essential elements of successful disparities interventions: why are they important, and how can you operationalize them in your organization?

Foster a Culture of Equity

WHY IS IT IMPORTANT? Your intervention is more likely to be successful if the entire staff recognizes that disparities exist in your organization and is ready to take responsibility for them.

WHAT WILL WE GET OUT OF IT? Staff will share a definition of equitable care and place high value on its delivery. There will be a generalized commitment to disparities reduction and a willingness to prioritize it.

HOW CAN WE MAKE IT HAPPEN?

• Designate specific leaders for disparities reduction—more than one!
• Identify and recognize equity champions.
• Recruit a diverse workforce that reflects the population you serve.
• Tie compensation to quality goals that include disparities reduction.
• Have a community advisory board.
• Have strong relationships with community-based organizations.
• Always consider how quality improvement affects different patients differently.

For more information on how to foster a culture of equity, go to Step 2 of the Road Map.

CASE IN POINT

The Board of Trustees at Harvard Vanguard Medical Associates voted to include equity as a core component of its quality improvement strategy. In a process evaluation, their leaders cited this as an
indicator that the organization was prepared to implement a disparities intervention.

Incorporate disparities interventions into existing systems.

WHY IS IT IMPORTANT? New programs may create redundant efforts or conflicting goals with existing initiatives.

WHAT WILL WE GET OUT OF IT? Integrating disparities work into quality improvement promotes the feasibility and sustainability of the initiative. Workloads and schedules will be more manageable, and disruptions and inconsistencies will be minimized.

HOW CAN WE MAKE IT HAPPEN?

Avoid entirely separate programs. Instead, integrate equity activities into existing systems. These may include:

• technological platforms (e.g. electronic medical records)
• QI projects (e.g. PCMH accreditation)
• clinic flow (e.g. standing staff meetings
• mandates (e.g. REL data collection)
• resources (e.g. diabetes educators)

For more information on assessing existing systems, visit Step X of the Road Map.

CASE IN POINT

 

University of Pennsylvania harnessed a policy shift to the Patient Centered Medical Home model to gain access to an EMR system and an on-site health educator. They were then able to incorporate these components into their disparities intervention.

Involve members of your target population during program planning.

WHY IS IT IMPORTANT? If you don’t work with the people you want to serve, your intervention may be irrelevant, under-utilized, and/or ineffective.

WHAT WILL WE GET OUT OF IT? Your program is more likely to be effective and adaptive. Your organization will also advance its community engagement.

HOW CAN WE MAKE IT HAPPEN?

• Don’t use minority health workers as proxies for minority patients.
• Get the input of your CAB on a) how to design your intervention and b) how to engage community members in the design process.
• Solicit feedback directly from patients. Then don’t forget to report back to them: how did you incorporate their suggestions? What were the results?
• Meaningfully involve patients in every step of the roadmap.

This is an ongoing theme throughout The Road Map to Reduce Disparities.

CASE IN POINT

Neighborhood Health Plan of Rhode Island implemented a telephone-based care management program targeting Latinos with diabetes, but the Latino community showed little interest in participating. Focus groups with Latino patients revealed that the strategy to recruit participants by phone used valuable cell phone minutes. The organization had invited Latino doctors and nurses to help design the intervention, but patient and provider perspectives of the intervention differed despite their shared ethnicity.

Appoint staff to disparities reduction initiatives.

WHY IS IT IMPORTANT? A plan to improve equity requires human resources. Your team needs protected time to plan and implement disparities interventions.

WHAT WILL WE GET OUT OF IT? When staff is officially appointed to your initiative, the project is more likely to get the time it needs. You’ll also avoid staff burnout.

HOW CAN WE MAKE IT HAPPEN?

• Protect staff time for equity activities.
• Bring in new hires or shift responsibilities to account for increased workload.
• Incorporate equity activities into existing QI, so one team can work on both initiatives.
• Plan for staff turn-over.

For more strategies related to staffing your disparities intervention, go to Step 6 of the Road Map.

CASE IN POINT

Choctaw Nation Health Services Authority engaged CHWs to teach diabetes self-management to patients. Rather than hiring additional staff to support the effort, the project team assigned these new tasks to existing CHWs, generating resentment and resistance among even their best workers. Process evaluation showed low fidelity to protocol; the program ultimately failed to improve outcomes.

Identify and appeal to the equity rationale that is most important to your audience.

WHY IS IT IMPORTANT? Your stakeholders will be motivated for different reasons. Understanding their priorities is essential to getting their buy-in.

WHAT WILL WE GET OUT OF IT? Your intervention will be better designed and supported by staff, patients, and community members. The implementation of the intervention is more likely to be efficient and accurate.

HOW CAN WE MAKE IT HAPPEN?

Organizational leadership may respond well to programs that guarantee a positive return on investment and leverage existing resources. Our product, Making the Case for Equity, outlines useful tips for addressing this audience.

• Present data demonstrating potential for positive financial impact.
• Take advantage of your existing systems and integrate new programs into them.
• Demonstrate how you’ll meet regulatory requirements.

Providers are often concerned with maximizing efficiency during the office visit.

• Consider strategies to enhance the care team. You may find helpful examples in the FAIR Database.
• Promote care management outside the clinic.

Front line staff may be wary of impacting patient flow and room availability.

• Acknowledge openly that this may result in an additional burden.
• Solicit suggestions on ways you can ease that burden.

Everyone cares about patient outcomes.

• Share your plan for disparities efforts at all levels of the organization.
• Report back to all levels of the organization: share the outcomes you measure.

For more information on approaching different equity audiences, visit Step 5 of the Road Map.

CASE IN POINT

Providers at the Yale University School of Medicine secured leadership buy-in by providing a justification and sustainability plan outlining potential increased billing and revenue streams.
Westside Health Services easily gained buy-in among providers by replacing the standard patient chart review with a second office visit conducted by a clinician peer. The visit focused exclusively on
cardiovascular disease and diabetes control, two of the clinic’s identified disparities.

Strike a balance between adherence and adaptability.

WHY IS IT IMPORTANT? While adherence to protocol ensures consistency, flexibility is key when working with diverse patients, who may have diverse needs.

WHAT WILL WE GET OUT OF IT? Your intervention will be consistent enough to scale up, while remaining effective in different patient populations.

HOW CAN WE MAKE IT HAPPEN?

• Use checklists to monitor adherence.
• Review the checklists regularly. Facilitate frank discussions about the feasibility of the intervention as described by protocol.
• Encourage staff and patients to give suggestions for adaptations.

For more information, go to Step X of the Road Map.

Be realistic on the time necessary to move the dial on disparities.

WHY IS IT IMPORTANT? Improvements in minority health take time because of multiple challenges inside and outside of the clinic.

WHAT WILL WE GET OUT OF IT? A realistic timeline manages expectations and maintains ongoing support for the project.

HOW CAN WE MAKE IT HAPPEN?

• Focus on process measures initially. They will help you understand the impact your intervention is having, before health outcomes improve.
• Plan long-term follow-up. Three years is usually realistic to demonstrate statistically significant improvements in health outcomes.
• Don’t forget to measure the gap. While overall improvement is promising, it may or may not indicate a reduction in disparities.

For more information, go to Step 6 of the Road Map.

CASE IN POINT

The HVMA intervention showed increases in provider awareness of disparities within the organization but was insufficient to improve diabetes outcomes among Black patients. Continued follow-up at HVMA may have revealed a significant clinical effect, as the two-year evaluation showed a trend in that direction.