Much has been written about the impact of COVID-19 being greater on African-American, Latino and Native American communities. But what are some steps health systems have taken to better care for these communities? Boston-based Mass General Brigham (the new name for Partners HealthCare) anticipated it would see a disproportionate impact and on March 16 launched an Equity and Community Health COVID Response Team.
During a May 19 webinar, Joseph Betancourt, M.D., M.P.H., vice president and chief equity and inclusion officer of Massachusetts General Hospital, introduced a team of Mass General Brigham leaders in describing multiple aspects of the health system’s response, with the hope that their lessons learned could be helpful to other healthcare systems.
Betancourt began by noting that historically disasters such as hurricanes and earthquakes hit minority populations much harder, with Hurricane Katrina a clear example. Similarly, he said, in a pandemic like this, vulnerable populations are at higher risk. “They come in with an unequal burden of disease. They live in situations where social determinants of health impact their health and well-being in a negative way,” he said. Monitoring the neighborhoods they serve helped drive their strategy as a system.
The health system targeted initiatives toward diverse communities such as Chelsea, Brockton, Lawrence, Lynn, and Revere, as well as certain neighborhoods in the City of Boston. MBG also monitored admitted patients for race, ethnicity, language, disability, gender and other factors.
Once formed, the MGB response team began meeting daily, and reported up through the incident command structure. They realized they had to prioritize speed over bureaucracy and be ready to forego normal processes, Betancourt said.
Initiatives included redeploying doctors and researchers, building a registry of multilingual clinicians, and enhancing clinical communications to patients and employees, and ensuring community access to updated information. “We anticipated that the social determinant of health crisis would be exacerbated and began to focus on how we might mitigate those,” Betancourt said. “We pivoted to a community-based public health equity COVID strategy in hot spots.”
Aswita Tan-McGrory, M.B.A., M.S.P.H., the deputy director of the Disparities Solutions Center at Mass General, said it helps to take a bird’s eye view of your whole organization and how people interact with it.
“If you have any hotlines, think about how to integrate interpreters, and that may mean standing up an IVR [interactive voice response system] in other languages,” she said.
In terms of registration and data collection, Mass General makes sure that it continues to monitor the data it gathers on race, ethnicity and language. “We do have to address some of the challenges that happen during these times about collecting this information if a patient gets intubated as soon as they arrive the hospital or because of the level of urgency in place,” Tan-McGrory said. “We have worked with the registrars to collect this data after the patient has been discharged.”
Working with the Epic EHR system, trying to enroll patients into MyChart has been an emphasis, “but we have to consider if it is available in other languages and how to make accommodations if not, Tan-McGrory said. “The idea of self-enrollment, we really have to let go of that. These patients may have technology and language barriers and this idea that you self-enroll in an English-speaking, tech-savvy portal – they may need some assistance, so we have to work on that.”
In the ambulatory setting, there has been a real shift to virtual care. “We have to think about what platforms will allow interpreters to be integrated. In the inpatient setting, particularly the COVID floors, how do you integrate interpreters and preserve PPE? Is there a way to way to leverage our bilingual work force? Because these patients were not allowed visitors in our hospitals, how can we make sure they can communicate with families?”
She stressed it is important to stratify data by race, ethnicity and language and make sure they understand who the patients are and where they are coming from. “This is how we were able to identify that on our COVID floors, over 50 percent of our patients were Spanish speaking,” Tan-McGrory said. In terms of thinking about discharging patients to a recovery location, how do we integrate interpreter services there and what technology do you need to use? Thinking about remote monitoring programs — we have set these up for patients but they do need to be pretty savvy so how do you address the language component and technology barriers. We spent a considerable amount of time translating educational materials both for patients and employees.”
Multilingual Registry
Elena Olson, J.D., executive director of the Mass General Center for Diversity and Inclusion, described how they worked to leverage their multilingual work force for COVID needs. “So many of our patients and employees impacted by COVID are limited English proficient (LEP),” she said. “We decided that we wanted to create a multilingual staff directory that would include both clinicians and non-clinicians. We had research staff that had not been able to do their regular research, so there were a lot who were multilingual and available to help out. How could we collect this data and provide help with employee education as well as patient-facing operations?”
Unfortunately, the essential databases across MGB did not capture language data for employees. “We wanted to leverage the multilingual employees we had to help with COVID-facing operations, so we had to ensure that we knew who was multilingual and specifically who was proficient to a level of native proficiency,” Olson said. They used surveys to gather information about proficiency level and what kind of language certification people have. She said it is important to find out if people are qualified bilingual staff or even medical interpreters. They identified 2,400 multilingual staff in three weeks.
Spanish Language Care Group
Even though the registry was launched right out of the gate on March 16, the Spanish Language Care Group took a few weeks to launch. It was the brainchild of Joe Betancourt. He and Olson partnered with physicians running the COVID floors, ICUs, and emergency departments. Members of the Spanish Language Care Group are available 24x7. “They are M.Ds, they come from multiple departments, and they are able to help the care teams with daily rounding, family updates, admissions, discharges, informed consent, family meetings, goals of care,” Olson said. This group also developed 16 instructional educational videos in Spanish, which are available for the public to use.
Equity in Virtual Care
The equity effort extended to how MGB conducted telehealth visits. Lee Schwamm, M.D., MGB’s vice president of virtual care, said he is focused on expanding virtual care from a boutique offering that has largely been adopted by patients who are highly digitally literate and with higher health literacy, and often wealthier and English speaking.
“COVID really challenged us to make sure that our virtual health solutions could have the same kind of equitable reach as our in-person care so that meant connecting with folks who focus on medical interpretation to make sure we could provide medical interpreters to them through the same channel,” Schwamm said. “It also meant making sure that we thought about systems to engage our patients both into our electronic health record as the primary gateway to doing virtual visits, but also to think about the patients who for whatever reason were unable or reluctant to use that channel and provide alternative channels to connect those patients to their physicians.”
Another issue that came up, Schwamm said, is making sure MGB didn’t hard-wire inequity into the payment system by having no or inadequate payment for telephone visits, particularly for patients who can’t do video interactions. “From a clinical perspective, most would agree that video adds a tremendous amount of information and facilitates an encounter, particularly for new patients, we can’t forget the importance of telephone and texting and other forms of asynchronous exchange.” He said it is important that “leaders of organizations trying to find the path forward in this new world order of ambulatory care in the era of COVID ensure that there are guardrails in place to make sure we have equitable access for all our patients.”
