Tackling the Health Outcome Disparity Gap Together:

A Primary Care Based Collaborative to Reduce Behavioral Health Outcome Disparities Associated with Race and Ethnicity

Karen D. Lloyd, PhD, LPArt Wineman, MD

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # C4a in Period 4 October 17, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

1. Identify 5 barriers to best health care provision and health outcomes in diverse populations.

2. Define 3 new ways to think about and analyze improvement opportunities to close health outcome disparities.

3. Describe how HealthPartners has and other organizations may work to obtain improved health outcomes with communities of color and immigrant communities.

Bibliography / Reference

1. The HHS Action Plan to Reduce Racial and Ethnic Health Disparities: A Nation Free of Disparities in Health and Healthcare, Department of Health and Human Services, USA, 2011.

2. Centers for Disease Control and Prevention, Health Disparities and Inequalities Report, United States, 2011. MMWR 2011; 60(Supplement): 1-114.

3. U.S. Department of Health and Human Services. National Center on Minority Health and Health Disparities. Social Determinants of Health Initiative.

4. Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial. Wells K, Sherbourne C, Schoenbaum M, Ettner S, Duan N, Miranda J, Unützer J, Rubenstein L. Arch Gen Psychiatry. 2004 Apr;61(4):378-86

5. Interventions for enhancing medication adherence, Nieuwlaat R1, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, Agoritsas T, Mistry N, Iorio A, Jack S, Sivaramalingam B, Iserman E, Mustafa RA, Jedraszewski D, Cotoi C, Haynes RB, Cochrane Database Syst Rev. 2014 Nov 20;11:CD000011. doi: 10.1002/14651858.CD000011.pub4.

6. Institute of Medicine (IOM). In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce. Washington, DC: The National Academies Press; 2004.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Agenda

3

1 Organizational Background

2 Diversity and barriers to health in diverse populations

Opportunities to reduce disparities in health outcomes

4 Specific examples and HealthPartners learnings

22,500employees

1,500,000members

1,000,000patients

Our Care Delivery System:

Hospitals HealthPartners Medical Group ClinicsPark Nicollet Health ServicesSpecialty Centers

Hospitals

Regions454-bed, level 1 trauma

Lakeview97-bed, acute care

Hudson25-bed, critical access

Westfields25-bed, critical access

Methodist426-bed, acute care

Amery25-bed, critical access

1,700physicians

55+specialties

50primary care locations

Our Ambulatory Practice

60+dentists

22locations

10

Our Ambulatory Practice

28Urgent Care locations

8Urgency Room level care

9Urgent Care + Retail Clinic level care

Mission

Vision

Values

To improve health and well-being in partnership with our members, patients and community

Health as it could be, affordability as it must be, through relationships built on trust

Excellence | Compassion | Partnership | Integrity

About HealthPartners

Diversity in Minnesota

Source: MNcompass

Patients We Serve

White

Black or A

frica

n-Americ

anAsia

n

Hispanic

or Latino

American-In

dian or Alaska

Native

Other0%

10%

20%

30%

40%

50%

60%

70%

80%

Active* HPMG Patients (2014) Twin Cities 7-county region (2014)

Seek First to Understand

• Barriers to health in diverse populations:– Cultural – Language– Financial – Transportation– Complexity of health care system

Approaches to Reduce Disparities

• Use plain language and “teach back”• Offer options• Convenience• Ensure follow-up care• Offer incentives• Make use of all opportunities• Community collaboration• Develop innovative engagement approaches

Offer Options

• Primary Care:– FIT testing vs.

colonoscopy

• Behavioral Health:– Beating the Blues

Convenience

• Primary Care:– Same day

mammograms

• Behavioral Health:– “Population Health

Clinic”• Centrally located

walk-in BH clinic• Tele-health BH

prescriber links to all Primary Care clinics

Ensure Follow-Up Care

• Primary Care:– Diabetes registry

• Behavioral Health:– Registry for

depression in primary care

– Depression Care Managers

– On Your Way©

– First Fill program

Make Use of All Opportunities

• The vital role of Interpreters with immigrant populations– Avoid assuming language abilities

• Especially regarding topics outside every day conversation

– Avoid using family members– Ask Interpreters to relay all info

• HealthPartners Interpreter Services employees– Language Line only if necessary

Make Use of All Opportunities

• Primary Care:– Health Care

Maintenance reminders– Best Practice alerts– PHQ-9 screenings for all

depressed patients– When depression fails

to resolve• Depression Care

Manager

• Behavioral Health:– PHQ-9 screenings

for all depressed patients

• Psychiatric

consultation

• Possible referral

for a “tune up”

Depression Care

Manager

Incentives

• Immunizations• Asthma Management• Healthy Pregnancy• Car Seat Program• Preventive Dental • Others

• To defray expense of antidepressant costs

• For high risk members:– Completion of a CD

face to face eval– Attendance at X appts

Behavioral Health Incentives

• $10 to $75 for completing a variety of health improving activities

• Personalized health activities with verification• Invite only those with opportunities

– Completing a CD face to face evaluation– Attending 3 psychiatry visits – Attending 3 primary care visits– Having 5 telephone dialogs with a BH care coordinator – Completing a 21 day chemical dependency program

Behavioral Health Incentives

2014 data:• Just over 100,000 Medicaid health plan

members • 5,013 were identified as at high risk for

psychiatric hospitalization • 2051 were engaged in Behavioral Health Case

Management (41%)• 97 members earned gift cards (5%)

Mental Health Stigma in Diverse Communities

• Stigma due to cultural or historical factors• Reducing / eliminating stigma though

community enlightenment and education• Collaborative planning• Partners:

– HealthPartners– NAMI MN (National Alliance on Mental Illness)– Twin Cities Public Television (TPT Channel 2)

Community Collaboration

• Primary Care:– Como Health Club

• Behavioral Health:– MakeItOK.org

• County Public Health• Community Mental

Health Clinics• Hospitals• Employers

– Minnesota State Baptist Convention

http://www.makeitok.orghttp://makeitok.org/interactive/organization-ready/

Make It OK

Engaging Individuals from Diverse Populations• On Your Way©

– Health education newsletters– Just in time refill reminders– Missed refill reminders– Prescriber alerts

• First Fill Antidepressant Program– Phone outreach– Education and support– Incentives

Primary Care / Health Plan Collaboration• Referrals from Primary Care to Centralized Behavioral

Health Services – SBIRT– BH Case Management – Chronic Pain / Opioid– Urgent Access to Psychiatry

• When system does not have capacity• Documentation in EMR

– Referred cases– Proactive outreach for high risk patients

Case Example

Colorectal cancer screening to antidepressant continuation• Same health processes for all patients but add extra

attention to dissolve the unique barriers of diverse populations

• Prompts to action delivered reliably• Personal conversations between clinicians and

patients • Convenience for patient• Incentives as needed

69.2%78.7%

43.0%

65.6%

0%

20%

40%

60%

80%

100%

1st Qtr 2009 4th Qtr 2014

white patients patients of color*

GAP is 13.1% pointsGAP is

26.2% points

*Black and Native American patients start screening at age 45, age 50 for all other races.

HEDIS 2014 National 90th Percentile= 71.6%

Reducing the Gap: RaceColorectal Cancer Screening

Colon Cancer Screening:

Implement decision support in EHR

Specific messaging and education

Shared decision making- FIT/colonoscopy

Specialty and Primary Collaboration

Outreach - Letters, calls, and more letters

2GoBox

Interventions that have worked

• Sold at our clinic pharmacies• Includes:

– Prep materials– Information on the

procedure– Humor: ‘Do not Disturb

(Seriously)’ door hanger– Games to help pass time

• Won 2013 Graphic Design USA, American Package Design Award

Colonoscopy 2-Go Box

Health Disparities Opportunity

• Close the gap opportunities• 2014 Antidepressant Continuation (6 months)

Commercial = 57.7%

Medicaid = 34.8%

White pts = 38.7%

Pts of color = 29.5%

Gap of 22.9 percentage points

Gap of 9.2 percentage points

Universal Care Delivery Process

• Same health processes for all patients but add extra attention to dissolve the unique barriers of diverse populations. – PHQ-9 for all– Added supports for people of color– In lieu of PHQ-9, Georgi Kroupin, PhD created a short

standardized questionnaire (Center for International Health)

– MN Dept Human Services: MH Screening for Immigrants

Universal Health Plan Process

• Same health processes for all members but add extra attention to dissolve the unique barriers of diverse populations. – First fill phone calls– Overdue refill phone calls– Incentive / gift card to defray expenses

Universal Enterprise Process

• Online interactive Beating the Blues– 5th grade reading level– Personalized invitation from primary care

physician, clinic based depression care manager, health plan

• Reducing MH stigma through Make It OK– Outreach through county public health

departments– Outreach to faith community

Quality Improvement Cycle

• It often takes 5 years to improve population health• It takes more effort if there is stigma or lack of cultural

understanding• New innovations must be developed, implemented and

evaluated • Our data from colorectal cancer screening suggests 5

years is a reasonable QI cycle• Our first year data on antidepressant focus resulted in

little movement

Lessons of Working Collaboratively to Reduce Health Outcome Disparities

• Thinking outside the box is one thing---putting it into action is quite another… – Fear of trying something new which alters your

typical work and typical roles– Fear of failing in public and being humiliated– Fear of disappointing others and losing credibility– Fear of the hard work it takes to create and

implement new protocols – Fear of getting guidance from & taking direction

from those you consider outside “My Team”

Collaboration Success Factors

– Triple Aim culture– Trust among leaders representing a variety

of areas and perspectives– Mutual encouragement to tackle the hard

problems– Creativity plus deep clinical expertise in

care and care support processes– Courage to move from the conceptual to

the practical--trying “what has never been”

Collaboration Success Factors

– Listening sincerely to input from the front line and patients and believing their input

– Finding champions among physician leaders to pilot, refine and prepare for spread

– Creating a dependably consistent process and maintaining accountability by calling out the score with meaningful metrics

– Momentum helps to overcome habitual ways of thinking and acting

Customize for Care that Meets Individual Needs

Equality Equity

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!