This year has seen many health systems make pronouncements about health equity, but do they actually have a plan to address inequities and structural racism? Minnesota-based Allina Health is using a data-driven approach and is creating the infrastructure to support and implement interventions targeting disparities.
Allina Health, based in Minneapolis, encompasses 90-plus clinics, 11 hospitals, 11 retail pharmacies, specialty care centers and specialty medical services, home care, home oxygen and medical equipment, and emergency medical transportation services.
Vivian Anugwom, the organization’s health equity manager, detailed Allina’s approach during a talk she gave at the recent Healthcare Analytics Summit put on by Health Catalyst. “Equity is about ensuring that we tailor the care we provide to the communities and patients we serve so we are caring for them in the way they want to be cared for,” she said.
Although the pandemic has magnified health disparities, she said, they have always existed. “We need immediate and long-term solutions to address structural racism and health-related social needs that are among the root causes of health disparities.”
Anugwom offered a few key considerations critical to ensuring a healthcare organization commits and stays committed to eliminating health disparities.
First, she said, it is important to attach health equity efforts to key strategic initiatives. “We have attached health equity to our commitment to providing safe and high-quality care. We have an executive sponsor, our chief medical officer, who is charged with carrying that message and ensuring that health equity is embedded into everything we do.”
Second, she added, it is necessary to identify and prioritize your disparities. “It is really crucial to create an infrastructure for support and implementation of any interventions you identify to get at the disparities. I have seen that if we don't have the resources or infrastructure to share the learnings, even internally, it is hard to continue the momentum of the work.”
At Allina Health, it is standard practice for them to include REAL (race, ethnicity, and language) filters on all dashboards. “It ensures that we have a way to drill down to specific outcomes and experiences of our diverse patient population,” Anugwom explained. “You need the data to understand inequities.”
It is crucial to use the data to identify opportunities you might have in your health system, but you also need to ensure you have a way to understand social factors, she said. How do you connect with the community to be sure you understand their values, beliefs and how health-related social needs have an impact on outcomes? Housing stability, financial concerns, food insecurity – those are some things you don’t necessarily see in the data, but the data helps you uncover opportunities to do community engagement to tell the rest of the story, Anugwom noted.
Once you have noticed something in the data, the next step is understanding the root causes and identifying solutions within Allina’s influence. One way is to dig into literature associated with the disparities you have uncovered; another is to talk to the community. “It is crucial for us to get outside our meeting rooms,” she said. “If we have seen certain disparities, let’s talk to patients who are experiencing them and understand the root causes. Then we can get into prioritizing interventions we can co-develop with the community.”
Anugwom stressed that it is crucial for health equity work to be resourced well, and interventions that prove to be successful are embedded into ongoing operations. “If you have taken the time to engage the community and seek their perspectives, and shown what you want to do to get at the disparities, then to make sure you maintain the trust and relationships, you have to have enough resources allocated to keep interventions going.”
Allina has identified a long list of disparities it could try to address. How does it prioritize? Anugwom said they start with a few questions:
• Are there solutions within our sphere of influence?
• Is the disparity clinically significant?
• Is there meaningful impact to the community?
• Could the solutions drive value?
To the last question, Anugwom said: “I would like to be optimistic that we will continue to want to do the right thing for underserved communities, but we have to be clear on what the financial value is, so that it is harder to cut interventions that we develop.”
Anugwom gave one example of an initiative launched at Allina recently. Their data revealed that the African-American populations receiving care at Allina Health were not enrolling in hospice programs at the same rate when they were eligible because the hospitalists weren’t referring African-Americans at the same rate as other populations. Anugwom and her team implemented new measures including implicit bias trainings to help address and overcome these biases to ensure health equity for all.
“We thought that first it was crucial to first understand why these patients were not being referred if they were eligible,” she said. “Before we engaged the community, we decided to look internally at what we can we do better.” Research literature suggests that African-American patients prefer aggressive treatments and are more likely to mistrust healthcare providers. Also, they tend to prefer to care for family to the end of life at home. “As we were talking to providers, we heard the same thing from their perspective,” she said.
In the implicit bias training it offers to physicians, Allina works to help them have a general understanding of norms and beliefs but also to individuate patients. “We want to ensure you are treating the patient as an individual,” Anugwom said. “Recognize situations that magnify stereotyping and bias. Pause and check your assumptions and individuate patients. We are looking to expand our implicit bias training to be more general so we can train providers to be more inclusive of minority groups.”
Allina is going through a prioritization process of things to work on next. One is hypertension in Black moms. “We want to ensure we are doing all we can upstream to ensure Black moms are not coming in with unmanaged hypertension,” Anugwom said.
Another is expanded outreach mechanisms to close that gap on colorectal cancer screening in Black men. In another example, they saw opportunities to provide better care for the Somali patient population, who have been disproportionately affected by COVID, by opening more testing sites, hiring imams in their large hospital in Minneapolis, and creating culturally responsive care training.
“We have opportunities to serve more diverse populations with culturally responsive care,” Anugwom said. “I would love to work myself out of a job by helping teams build skills and knowledge to do this disparity work. I have provider champions, and I am working with folks across the system to help them understand their role in eliminating disparities and giving them the tools to do that.”