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Transforming Care: Identifying and Addressing Health Disparities Among Hispanics

Transforming Care: Reporting on Health System Improvement

A quarterly focused on new models of care, payment, and patient engagement for the nation's sickest and most vulnerable.

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In Focus: Identifying and Addressing Health Disparities Among Hispanics

Photo of Las Colonias

Some Hispanics live in unincorporated areas along the U.S.-Mexico border known as las colonias, where health and other services are scant. University of New Mexico faculty, medical residents, and students serve residents of las colonias through a Blue Cross Blue Shield mobile health van.

Some Hispanics live in unincorporated areas along the U.S.-Mexico border known as las colonias, where health and other services are scant. University of New Mexico faculty, medical residents, and students serve residents of las colonias through a Blue Cross Blue Shield mobile health van.

Hispanics make up the largest and fastest-growing minority group in the U.S. For decades, health services researchers have puzzled over a paradox among them: Hispanics live longer and have lower death rates from heart disease, cancer, and many of the other leading causes of death than non-Hispanic white residents despite having social disadvantages, including lower incomes and worse access to health coverage. There are many theories why, including the stronger social networks, healthier eating habits, and lower smoking rates among some Hispanic groups, particularly newer arrivals.

But focusing on national data can mask important differences linked to whether Hispanics have health insurance, speak primarily Spanish or English, or grew up in the U.S. or another country. The very heterogeneity of the Hispanic population — they come from more than 20 countries, with widely differing experiences and social circumstances, including immigration status — makes it hard to pinpoint problems, including high rates of diabetes, liver disease, and certain cancers and poor birth outcomes among some Hispanic groups.1 A 2015 study from the Centers for Disease Control and Prevention (CDC) was the first to examine health indicators by Hispanics’ country of origin and whether they were born in the U.S. — shining light on important differences. (See Q&A with Ana Penman-Aguilar, Ph.D., M.P.H., chief science officer and associate director for science at the CDC’s Office of Minority Health and Health Equity.)

In this issue of Transforming Care, we delve into efforts led by health care researchers, clinicians, and health plans to identify and address health disparities among the particular Hispanics they serve. It is a complement to our September issue, which examined efforts to address health disparities among African Americans.

The Paradoxes of Health Among Hispanics infographic

Culturally Targeted Approaches

Because nearly a third of Hispanics in the U.S. are not fluent in English, many efforts to engage them begin with translation. But focusing on language alone can fall short, especially if the translation doesn’t take into account cultural differences.

CalViva Health, a health plan serving Medicaid beneficiaries in California’s Fresno, Kings, and Madera counties, with support from Health Net, a larger Medicaid plan, uses quality and claims data to identify disparities among its members and then conducts interviews with patients and clinicians to uncover what may be fueling them. This approach revealed that in one rural clinic serving mostly Hispanic patients, many from El Salvador, only half of women attended postpartum visits between 21 and 56 days after delivery (as tracked by the HEDIS performance measure). By comparison, in a nearby urban clinic also serving predominantly Hispanic patients though fewer Salvadorians, 73 percent of women had timely postpartum visits.

The interviews revealed that many Salvadorian women follow the traditional practice of quarantining themselves after delivery: remaining in their homes for 40 days and covering their ears, nose, and other body parts to prevent evil spirits from entering the body. “Providers didn’t understand why they were coming in very heavily dressed, with ear plugs and long pants or sweats and socks in the summer and the members told us they felt their cultural practices weren’t being acknowledged,” said Eulalia Witrago, M.P.H, a senior cultural and linguistic specialist at Health Net.

To encourage more Salvadorian women to attend postpartum visits, staff worked with clinics to educate clinicians about the quarantine practice and included a question (created in conjunction with Salvadorian women) to the obstetric history form about women’s cultural beliefs. CalViva staff have also helped clinics set up electronic reminders to schedule postpartum visits during women’s 35th week of pregnancy.

Navigation for Patients and Clinicians

Seattle-based Harborview Medical Center has long experience navigating patients’ cultural traditions. For 24 years, cultural mediators have offered interpretation, health education, case management, and advocacy to patients with African, Asian, and other backgrounds; about 40 percent are Spanish speakers, and many are undocumented and/or uninsured. “It’s a really unique program,” says Lea Ann Miyagawa, M.N., R.N., assistant nurse manager of Community House Calls. “There’s nothing else in the state like it and very few like it in the country.”

Harborview pays for the program, including the salaries of eight staff cultural mediators. Some help patients by attending their medical appointments, visiting them in their homes, and connecting them with primary care and other supports. (See Q&A with Rosemary Cano, one of Harborview’s cultural mediators.) Others work with hospitalized patients to make sure they understand their treatment options. “I try to get to patients and their families as soon as possible,” says José Mayorga, a cultural mediator who works with Hispanics who are hospitalized because they’ve had traumatic accidents, are undergoing surgery, or are seriously ill. Clinicians can refer patients to Mayorga, and he also reaches out to patients who’ve indicated they prefer Spanish-language communication and/or have Hispanic-sounding surnames.

Mayorga takes into account patients’ age, country of origin, and level of education and often relies on metaphors that are relevant to their life experiences to help them understand procedures. “If a patient needs debriding of the toe, I ask ‘What do you do when you’re landscaping and find a tree with dead branches?’ They will say ‘Cut to the healthy part.’”

He also encourages clinicians to carefully consider their words, particularly related to end-of-life decision making. Hispanics are less likely than white patients to have documented their end-of-life wishes, and in some cases their religious beliefs and distrust about physicians’ motives may complicate conversations about palliative care and end of life. “If a doctor is not careful and says, ‘There is nothing else I can do,’ patients may think the doctor’s knowledge is at its limits and say, “Let’s find a second opinion,’” he says. “But if a doctor explains that all efforts to save the patient were done, it will ease the process.”

Mayorga has also helped honor Hispanic families’ traditions, once arranging for a priest to serve first communion to a child suffering from severe burns who was not expected to recover, and another time holding a quinceañera, or girl’s 15th birthday party, in the hospital so a sick grandfather could attend. “No mariachis,” he said, “but we had a party.”

Using Community Health Workers

Many efforts to address health disparities among Hispanics rely on promotores de salud, or community health workers. In Arizona’s Pima County, home to Tucson with a population that is over a third Hispanic, an effort funded through a CDC REACH (Racial and Ethnic Approaches to Community Health) grant launched in 2008 deployed promotores to educate Hispanics about the risks of cervical cancer. At that time, cervical cancer rates among Hispanic women were twice those among whites, and they were 50 percent more likely to die from the disease. 

The initiative was led by Francisco Garcia, M.D., distinguished outreach professor of public health, obstetrics, and gynecology at the University of Arizona and the son of a local promotora. Garcia worked with a group of promotores from Tucson’s Mexican-American community to adapt a cervical cancer curriculum that had been designed for medical professionals for lay audiences. The promotores then used this curriculum to train other women to spread the word about the risks of HPV infection, including developing cervical and other cancers, and the importance of having regular Pap smears and getting the HPV vaccine, which since its 2006 introduction in the U.S. had begun to reduce cervical cancer mortality, but had not been well publicized among Hispanic communities.

This approach spread over six years and trained 700 women to serve as cervical cancer promotores throughout Arizona and beyond, reaching an estimated 12,500 people by partnering with county health departments, family planning clinics, and community health centers. They also gave presentations in churches and schools and held barbecues and mother/daughter teas, once even setting up a presentation in the produce section of a grocery store.

“Eventually the program become so popular, anywhere the promotores would go women would pull them aside to ask for information or help navigating the health care system,” says Martha Moore-Monroy, M.A., lecturer in public health and program manager at the University of Arizona. Surveys among people who saw the presentations found that nearly all understood the common modes of HPV transmission and its risks. In addition to providing information and health system navigation, the program led some clinics to change their cervical cancer prevention and treatment practices.

Photo of Las Colonias

Some Hispanics live in unincorporated areas along the U.S.-Mexico border known as las colonias, where health and other services are scant. University of New Mexico faculty, medical residents, and students serve residents of las colonias through a Blue Cross Blue Shield mobile health van.

Identifying Behavioral Health Problems

Hispanics are less likely to receive treatment for depression, anxiety, and other behavioral problems than white patients because of barriers to accessing care and stigma surrounding behavioral health problems. Salud Family Health Centers, a federally qualified health center with 14 clinics and one mobile unit that treats many Hispanics in Northeast Colorado, has for 20 years integrated behavioral health into primary care to encourage more people to get treatment. All patients are regularly screened for depression and other problems then offered immediate consults with a behavioral health provider. “We just go in and say, ‘I am part of your care team,’” says Jonathan Muther, Ph.D., a psychologist and Salud’s vice president of medical services. “We say, ‘Your primary care provider is going to work with physical needs. I would like to work on other aspects of your health including your mood and stress. Can I ask questions we ask all of our patients?’ This approach can be powerful in that it normalizes behavioral health care.”

Many Hispanic patients’ behavioral problems are rooted in stress related to their immigration status and/or traumatic experiences in their home countries. “Family splitting is really, really tough, with some parents in Mexico, some parents here,” says Muther. “And we hear on a daily basis stories about the violence in Mexico: a mom whose son was kidnapped in Mexico and she hasn’t heard from him in a month. Or a patient who experiences suicidal ideation and trauma linked to having been recruited by a gang in Mexico.”

Salud’s social workers and counselors, most of whom are bilingual, offer short-term therapy focused on remediating symptoms and coping strategies, since most patients only come once or twice. “We only get one or two cracks at it with our patients,” Muther says.

Effects of Immigration Enforcement on Health

Evidence indicates that immigration policy and enforcement have an effect on the health of Hispanic immigrants by increasing stress and discouraging people from seeking care. And newer research suggests that stressors related to immigration can have a spillover effect on the health and wellbeing of U.S.-born Hispanics (i.e., those not subject to deportation) as well as foreign-born Hispanics. One study found that Hispanic babies born in Iowa in 2008 — the year following the largest Immigration and Customs Enforcement Agency raid to date, at an Iowa meatpacking plant — were 24 percent more likely to be born with low birth weight than the year before the raid. Rates increased among babies of both U.S.-born and foreign-born Hispanic women, but not among babies born to white women.

Collaborative Care for “Diapression”

Behavioral health problems, particularly depression, can complicate efforts to engage Hispanics in their health. In particular, many Hispanics living with diabetes also have depression, and each of the conditions can worsen and make it harder to manage the other — a syndrome so pervasive that some refer to it as “diapression.”

University of Southern California researchers have been experimenting with ways to adapt proven approaches to managing comorbid diabetes and depression to the needs of low-income, Hispanic patients. They’ve borrowed the IMPACT model of depression care — in which nurses or psychologists offer education, care management, and antidepressant medication and/or therapy — but added social workers to the care teams to help patients manage their financial, social, and emotional problems. In a randomized control trial at two Los Angeles County primary care clinics, the approach worked better than the usual care in reducing patients’ depression symptoms.

Since then, the researchers have leveraged technology in an effort to make this approach financially feasible across Los Angeles County, the nation’s second-largest safety-net system in which about 30 percent of Hispanic diabetic patients also have depression. They created an algorithm to review an electronic disease registry and identify diabetic patients, and then use automated calls with interactive voice response to screen them each quarter for depression. Patients use keypads or natural speech to answer questions about their depressive symptoms, pain, management of their condition, and physical and social activities.

Those who screen positive for depression then receive monthly calls, during which an artificial intelligence persona known as “Amy” asks about their symptoms, whether they are adhering to prescribed antidepressant medication, and whether they’ve been using problem-solving approaches. Patients select the call times and language and the questions are tailored to their particular circumstances and responses. After each call, patients’ care teams receive updates about their progress and reminders to follow up about identified issues.

In a six-month trial comparing this approach with the usual depression care and the social worker–led IMPACT model, the technology-facilitated approach proved as effective as the social worker/IMPACT model in reducing depression symptoms and prevalence (and more effective than usual care). Only the technology-facilitated model was associated with improvement in diabetes control measures (i.e., reduced cholesterol levels and greater likelihood of getting an HbA1c test) and depression remission. And patients using the technology were more satisfied with their care, perhaps because it reduced the stigma of talking about depression. “Patients told us they felt comfortable reporting their symptoms to an automated system and felt there was no judgment,” says Shinyi Wu, Ph.D., a systems engineer at the University of Southern California. Wu also noted the approach may have been effective because the interactive voice response system didn’t require low-income patients, who often have low literacy, to read written materials.”

Targeting Maternal Health

Overall, Hispanic women tend to have similar, or in some cases better, birth outcomes as non-Hispanic whites, but Puerto Rican women fare worse than whites. Babies born to Puerto Rican women are more likely to be low birth weight and to die during their first year of life than white and other Hispanic babies. Puerto Ricans also have a high prevalence of type 2 diabetes, a risk factor for adverse pregnancy outcomes.

Researchers from the University of Massachusetts in Amherst, Mass., have been engaging Puerto Rican women during their pregnancies to disrupt what can often become a continuum of obesity, gestational diabetes, and subsequent type 2 diabetes. “Pregnancy is a teachable moment for women,” says Lisa Chasan-Taber, Sc.D., a University of Massachusetts professor of epidemiology. “They have a number of contacts with the health care system during their prenatal appointments, and are often motivated to make changes for themselves and their babies.”

Chasan-Taber and her team have targeted two groups of Puerto Rican women: those who are overweight or obese at the beginning of their pregnancies, and women who develop gestational diabetes. They invite these women to work with health educators, many hired from the Puerto Rican community, to take modest, practical steps to increase their physical activity and healthy eating habits. “We’re not suggesting they come into the lab or get a gym membership,” says Chasan-Taber. “Even 10-minute bouts of moderate exercise or increasing their walking pace can be effective.” The health educators also help women modify their traditional diets to make them healthier.

Lessons

The experiences of health plans and clinicians working to identify and reduce health disparities among different groups of Hispanics offer lessons for others. Some may be applicable to other low-income groups who face obstacles to accessing care because of their work hours, lack of transportation, or lack of income to devote to health.

To help, some health systems are leveraging their buying power to create job opportunities for Hispanics. Baystate Brightwood Health Center, which serves predominantly Hispanics in Springfield, Mass., created a training program for personal care assistants to improve the economic prospects of its patients, who clinic leaders say have an average annual income of around $7,500.

But some issues affect Hispanics in particular, including the lack of trust in the health care system bred both by immigration challenges and the underrepresentation of Hispanics in health care professions. “I have been in practice for 30 years and the percentage of Hispanic physicians has dropped during that time,” says Judith Flores, M.D., chair of the National Hispanic Medical Association’s board of directors. The association offers mentoring programs for Hispanic physicians and has been studying ways to encourage Hispanics to enroll in medical school. Salud Family Health Centers, meanwhile, has had success training its own Hispanic clinicians, in part through an exchange program that brings psychologists from Chile and Puerto Rico to the Colorado clinics.

Leaders of many of the programs profiled here say it is important to acknowledge that immigration status affects health, even more so after the Trump administration proposed changes to the “public charge” rule that experts say could discourage legal immigrants from accessing Medicaid and other publicly funded health care services.

“Where you were born shouldn’t matter,” says Michelle Doty, M.P.H., Ph.D., vice president of Survey Research and Evaluation for the Commonwealth Fund, who has studied Hispanic health disparities. “Ensuring people can get help to prevent or treat problems is a public health concern. There are no boundaries where there is illness in community, and so it behooves us to take care of everyone.”

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NOTES

1 The heterogeneity of the population is reflected in lack of agreement about their name, with some preferring Hispanic and others preferring Latino or the gender-neutral Latinx, and in discussions of “race,” with some people identifying as both Hispanic and black other identifying as Hispanic and white. For this discussion, we use the term “Hispanic” to refer to all ethnic groups with roots in Latin America, Spain, or the Caribbean.

Q&A with Ana Penman-Aguilar: Diving in to Data on Hispanic Health

Ana Penman-Aguilar

A 2015 study led by the Centers for Disease Control and Prevention (CDC) was the first to use national data sources to analyze a broad range of health indicators for Hispanics by country or region of origin and according to whether people were born in the U.S. or abroad. We asked one of the study’s authors, Ana Penman-Aguilar, Ph.D., M.P.H., chief science officer and associate director for science at the CDC’s Office of Minority Health & Health Equity, to tell us what the analysis revealed and how the CDC has been working to reduce health disparities among Hispanics.

Transforming Care: What sorts of differences did you see in health outcomes and behaviors among different Hispanic subgroups?

Penman-Aguilar: We found that there is considerable variation in health by Hispanic origin subgroup and by whether someone was born in the U.S. or not. For example, Puerto Ricans in our study had nearly twice the prevalence of self-reported cancer (+84%) and heart disease (+87%) compared to Mexicans. They also had higher rates of self-reported smoking compared to Mexicans. As another example, whether people got the preventive screenings they needed varied by Hispanic subgroup. Our study provides a starting point for identifying specific Hispanic subgroups for targeted improvement of specific health indicators, such as preventive screening rates.

Transforming Care: Some subgroups of Hispanics fare better than whites on some measures of health despite experiencing worse access to care and having a lower socioeconomic status. What do you think might be at play?

Penman-Aguilar: Our study did not look at this issue specifically, but the literature provides some ideas. One important idea is that healthier people may be more likely than less healthy people to migrate to the U.S. Additionally, sick and elderly people may migrate back to their home country to receive palliative care or to prepare for subsequent death. Furthermore, as time spent in the U.S. increases, the health of Hispanic recent immigrants may deteriorate as they take on some less healthy behaviors of people in the United States overall.  

Another important factor is lower tobacco use among Hispanics. Hispanics are less likely than non-Hispanic whites to smoke and Hispanic smokers smoke fewer cigarettes than non-Hispanic white smokers. An analysis conducted by researchers from Princeton University and University of Pennsylvania suggested that nearly three-quarters of the difference in life expectancy at age 50 between Hispanics and non-Hispanic whites can be explained by smoking.

Transforming Care: Half of Hispanics will develop diabetes over their lifetimes, and they are much more likely than whites to develop serious complications and die from the disease. What has been most promising in recent years in terms of preventing or managing diabetes?

Penman-Aguilar: In March 2016 as part of the National Diabetes Prevention Program, the CDC released the new PreventT2 curriculum, which offers a culturally relevant Spanish translation of the English version, rather than a direct translation. And the National Diabetes Education Program has developed several items to advance Hispanic and Latino health. For example, the Kit El Camino hacia la Buena Salud / The Road to Health Toolkit provides resources for community health workers, promotores, and diabetes educators to start a community outreach program reinforcing the message that type 2 diabetes can be delayed or prevented.

Latino communities are hard hit by neighborhood conditions that contribute to obesity and type 2 diabetes. Income, education, unemployment, housing conditions, and neighborhood environment profoundly affect whether individuals will consume nutritious food and have options for physical activity. Too many communities lack safe places for physical activity or full-service grocery stores. Although the most important approach to solving problems like this is to increase neighborhood options, it is also sometimes possible to help people overcome barriers with tailored approaches such as the music video Movimento por su Vida, which uses dancing as a strategy to increase physical activity in the home.

Transforming Care: Are there other ways the CDC has promoted the use of community health workers to reduce Hispanic health disparities?

Penman-Aguilar: The CDC has several community health worker programs directed at those who work in diabetes, HIV/AIDs, cervical cancer, heart disease, high blood pressure, kidney disease, and other areas. For example, AMIGAS (“Ayudando a Las Mujeres con Información, Guía y Amor para su Salud” or “Helping Women with Information, Guidance, and Love for Their Health”) is a bilingual educational outreach intervention designed to help promotoras and other lay health educators increase cervical cancer screening among Hispanics who have rarely or never had a Pap test. CDC funded a randomized controlled trial that showed AMIGAS is effective in promoting cervical cancer screening (Pap tests) among Hispanics between ages 21 and 65 years.

Some of the other things CDC does to address the health of Hispanics and Latinos include providing funding to health departments, community-based organizations, universities, and other health partners that serve Hispanics and Latinos; conducting public health bilingual social marketing campaigns; and conducting research that advances Hispanic and Latino health. 

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Q&A with Rosemary Cano: Supporting Socially Vulnerable Patients in Managing Diabetes

Rosemary Cano

Rosemary Cano grew up speaking Spanish and English as her family moved back and forth between Seattle and Lima, Peru. Five years ago, Cano became one of eight “cultural mediators” in Harborview Medical Center’s Community House Calls program; the mediators offer interpretation, case management, and other services to help immigrant and refugee populations navigate the health care system. As part of her job, Cano educates Spanish-speaking patients who have poorly controlled diabetes about their disease and helps them overcome social and logistical obstacles to better health.

 

Transforming Care: Tell us about the patients you work with and the challenges they face.

Cano: A lot of our Spanish-speaking patients are dealing with day-to-day survival and therefore don’t prioritize chronic disease management until they find themselves in the hospital trying to avoid big consequences like amputation, blindness, or renal failure. Until that point, many think, “Why should I care about this long-term issue when I am more worried about being deported or finding a bed in the shelter or paying my rent and getting a job as a day laborer?”

Transforming Care: With these competing demands, how do you persuade them to take their health more seriously?

Cano: I tell people diabetes is not a life sentence — it is your companion on the highway of health and you need to drive it the way you drive a car, so it doesn’t drive you. I stress that ours is a prevention program where we catch people before they have serious complications. Prevention is a bit of a foreign concept for many. In the countries some of our patients come from, you only go to the doctor when you are really sick.

Transforming Care: What are some of the challenges the Hispanic patients you work with face in managing diabetes?

Cano: One of the most basic is transportation to medical appointments. It’s not just the distance and whether they have to find a babysitter, but also the price of the bus fare or gas. Because of the immigration raids, and the perceived anti-immigrant and anti-Latino atmosphere, I have had several patients tell me they prefer not to go outside. And then there is life stress. One of my patients has a four-year-old daughter who is autistic and needs to go to a lot of medical appointments. She and her husband also have deportation orders and frequent appointments with their lawyer. When she found out she had diabetes, she said I don’t have time for it.

Transforming Care: How might you help someone like her?

Cano: I showed her how to take the light rail, which cut down an hour on her transportation time. I also pointed out that walking to the station will help her manage her diabetes. I have gone with people to the Northwest Immigrants Rights Project to serve as an interpreter, to the food bank, and to the library to help people get their library card so they can have internet access.

Transforming Care: Do those sorts of services help?

Cano: Obviously we can’t do everything that patients need. But I think when they feel trust — and know we don’t share their information with immigration — it helps. We also stress here at Harborview we won’t judge you for not being able to read or write. About 25 percent of my patients are illiterate. Some know a few numbers so they can keep track of phone numbers.

Transforming Care: How do you work around that?

Cano: In my first year, it was by trial and error. I used a lot of pictures for medication instructions: a sun in the morning next to plate of food, that kind of thing. I had one patient from Mexico who was deaf and illiterate. Her parents never sent her to school. We did a lot of drawing. I put a frownie face next to a blood sugar reading of 150 or more and a smiley face for a reading below 150. Also we have 150 to 200 different rubber food models that I take to people’s homes to illustrate different food groups and practice portion sizes.

Transforming Care: What sort of results have you seen?

Cano: We found about a quarter of Harborview’s Spanish-speaking patients with type 2 diabetes have a hemoglobin A1c level greater than 9. When we looked at one cohort of 53 patients who received services from the cultural mediator program, we saw the mean level drop from 9.82 to 9.1 at three months, and then down to 8.86 at six months. At 24 months, the number was 8.99.

Transforming Care: What might it take to improve further?

Cano: It truly does take an interdisciplinary approach — going from the nutritionist to the pharmacist to the social worker to the doctor and the financial counselor may be a winding path, and I can help build some bridges with language and cultural understanding. Paying close attention to the mental health piece including “diapression” and “diabetic distress” can also help providers in their efforts to encourage patients to prioritize their own well being. Educating the care team about the role of a cultural mediator beyond “just an interpreter” is also key.  

Transforming Care: How often and how do you communicate with providers? Do you see the information you share changing the course of care?

Cano: On one occasion, I received a message from a provider that one of my patients was about to be discharged from the hospital back to the street. I knew this would be disastrous, having worked with this patient for over a year as he moved in and out of homeless shelters. He was always good-natured and never complained about his circumstances. But due to his memory issues and physical vulnerability he was constantly losing his belongings and was a target for thieves. He would disappear for weeks and develop extremely high blood sugar, which would inevitably send him back to the emergency department. I immediately messaged the entire team to advocate for the patient to stay in a transitional care unit. He was not released back to the street and his care plan has now changed for him to move to a long-term care facility.

Transforming Care: What advice would you give providers working with immigrant and refugee populations?  

Cano: I would say try to be cognizant of how hard it is for many of these patients to navigate the health care system, especially those with literacy challenges and limited financial resources. If they get handed a prescription or a referral, will they know where to go? Some may need help coordinating appointments, which can be difficult with the language barrier. Lastly I’d say try to ask patients how far they went in school. It could be the handouts are just wads of paper to them.

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Publications of Note: October—December 2018

Timely Follow-Up Not Associated With Reduced Hospitalizations for Homeless Patients with Mental Illnesses

A study examining whether timely outpatient follow-up after hospital discharge reduced the risk of subsequent hospitalization among homeless patients with mental illnesses found neither outpatient medical services nor laboratory services within seven days of discharge were associated with reduced likelihood of rehospitalization within two, six, or 12 months. More than half of the participants studied were rehospitalized within a year of the index discharge. The authors recommend addressing housing as a component of discharge planning, alongside outpatient care. Lauren B. Currie et al., “Continuity of Care Among People Experiencing Homelessness and Mental Illness: Does Community Followup Reduce Hospitalization?Health Services Research 53, no. 5 (Oct. 2018): 3400–15.

 

Maryland Health Enterprise Zone Lowers Hospitalization Rates, Total Costs

A study of Maryland’s Health Enterprise Zone, which was designed to enhance access to primary care in underserved communities and promote healthy behaviors, found the initiative was associated with a reduction of 18,562 hospital stays and an increase of 40,488 emergency department visits between 2013 and 2016 (the latter may be due to incentives encouraging use of observation visits). The net cost savings from reduced inpatient stays far outweighed the initiative’s cost to the state. As part of the effort, which provided behavioral health care, dental services, health education, and school-based health services, community health workers were deployed to underserved communities. Darrell J. Gaskin et al., “The Maryland Health Enterprise Zone Initiative Reduced Hospital Cost and Utilization in Underserved Communities,” Health Affairs 37, no. 10 (Oct. 2018): 1546–54.

 

Neighborhood Factors Associated with Readmission Risk at Urban Teaching Hospital

A study that sought to determine whether neighborhood characteristics, measured by the Area Deprivation Index, influenced patients’ readmission risk found patients residing in more disadvantaged neighborhoods had significantly higher 30-day readmission risks compared with those living in less disadvantaged neighborhoods. Those who lived in the most socioeconomically challenged neighborhoods were 70 percent more likely to be readmitted than those in less disadvantaged neighborhoods. Jianhui Hu, Amy J.H. Kind, and David Nerenz, “Area Deprivation Index Predicts Readmission Risk at Urban Teaching Hospital,American Journal of Medical Quality 33, no. 5 (Sept./Oct. 2018): 493–501.

 

Spending on High-Cost Dual Eligible Beneficiaries Tied to Long-Term Care Not Preventable Hospitalizations

A study that sought to determine what proportion of patients eligible for both Medicare and Medicaid (“dual eligibles”) had persistently high costs found more than half of high-cost beneficiaries remained so over a three-year period. These patients were younger than transiently high-cost beneficiaries, with fewer medical comorbidities and greater intellectual impairment. Persistently high-cost patients spent $161,224 per year compared with $86,333 per year for transiently high-cost patients and $22,352 per year dual eligibles who were not high cost. Most of the spending among persistently high-cost patients (68.8%) was related to long-term care, and very little (<1%) was related to potentially preventable hospitalizations for ambulatory care–sensitive conditions. Jose F. Figueroa et al., “Persistence and Drivers of High-Cost Status Among Dual-Eligible and Medicaid Beneficiaries: An Observational Study,” Annals of Internal Medicine 169, no. 8 (Oct. 2018): 528–34.

 

Wraparound Services Associated with Reduced Hospitalizations and Emergency Department Visits

The use of wraparound services, including behavioral health, social work, dietetics, patient navigation, and other services that address patients’ social and behavioral needs, reduced subsequent hospitalizations and emergency department visits among primary care patients at federally qualified health centers associated with Eskenazi Health, an Indianapolis, Ind.–based safety-net provider. Receipt of wraparound services produced estimated cost savings of $1.4 million annually. The authors note under value-based payment, wraparound services may be part of a portfolio of strategies to improve health and lower costs. Joshua R. Vest et al., “Indianapolis Provider’s Use of Wraparound Services Associated with Reduced Hospitalizations and Emergency Department Visits,” Health Affairs 37, no. 10 (Oct. 2018): 1555–61.

 

Supportive Housing Leads to Reduced Hospital Use for Elderly Medicare Beneficiaries

A study of a nonprofit, community-based program in Queens, New York, that supplied affordable housing with supportive social services to elderly Medicare beneficiaries found the program reduced hospital use, including admissions for ambulatory care–sensitive conditions. The evaluators found among residents of the buildings, hospitalization  rates were 32 percent lower, hospital lengths-of-stay one day shorter, and admissions for ambulatory care–sensitive conditions 30 percent lower than for their Medicare counterparts living in the same neighborhood but in different buildings. Michael K. Gusmano, Victor G. Rodwin, and Daniel Weisz, “Medicare Beneficiaries Living in Housing with Supportive Services Experienced Lower Hospital Use Than Others,” Health Affairs 37, no. 10 (Oct. 2018): 1562–9.

 

Supportive Housing Placement Reduces Preventable Health Care Visits Among Homeless Families

A study that assessed the impact of a New York City supportive housing program found 87 percent of supportive housing tenants remained in housing after two years. Compared with unstably housed heads of families in a comparison group, those in the intervention group were 40 percent less likely to make preventable emergency department visits. Sungwoo Lim et al., “Impact of a New York City Supportive Housing Program on Housing Stability and Preventive Health Care Among Homeless Families,” Health Services Research 33, no. 5 (Oct. 2018): 3437–54.

 

Marginal Changes in Spending on End-of-Life Care Among ACOs

A study of accountable care organizations (ACOs) in the Medicare Shared Savings Program detected changes in the end-of-life care among both decedents and patients at high risk of death, however, most effects were small and inconsistent across cohorts of ACOs entering the program in different years. The authors concluded that ACOs have not substantially altered end-of-life care patterns and that additional incentives or time may be needed to curb wasteful end-of-life care. They say it is also possible that curbing such spending may not be a viable source of substantial savings under population-based payment models. Lauren G. Gilstrap et al., “Changes in End-of-Life Care in the Medicare Shared Savings Program,” Health Affairs 37, no. 10 (Oct. 2018): 1693–1700.

 

Behavioral Health Integration and Complex Care Initiative in Medi-Cal Lowered Inpatient Cost, Improved Clinical Indicators

A large Medi-Cal managed care plan that addressed access challenges for enrollees with multiple chronic conditions by increasing staffing for care management, care coordination, and behavioral health integration found participation in the program was associated with improved clinical indicators for common chronic conditions, reduced inpatient costs in some sites, and improved patient experience in all sites. Todd P. Gilmer et al., “Evaluation of the Behavioral Health Integration and Complex Care Initiative in Medi-Cal,” Health Affairs 37, no. 9 (Sept. 2018): 1442–49.

 

Public–Private Partnership Addresses Maternal Mortality and Morbidity in California

As part of the California Maternal Quality Care Collaborative, public and private organizations partnered to lead maternal quality improvement activities that included linking public health surveillance to actions, including developing a rapid-cycle “Maternal Data Center” to support and sustain quality improvement activities. By 2013, California’s maternal mortality rate had been cut in half to a three-year average of 7.0 maternal deaths per 100,000 live births — comparable to the average rate in Western Europe (7.2 per 100,000). In contrast, maternal mortality rates worsened in the U.S. in the 2010s. Elliott K. Main, Cathie Markow, and Jeff Gould, “Addressing Maternal Mortality and Morbidity in California Through Public-Private Partnerships,” Health Affairs 37, no. 9 (Sept. 2018): 1484–93.

 

Good Candidates for Complex Care Management Are Older, Take More Medications, and Have More Outpatient Visits

A study that asked care managers working in intensive care management programs to determine whether referred patients were good candidates for care management found less than two-thirds were considered good candidates. Eighteen percent were categorized as not needing care management and 19 percent were categorized as needing more than traditional care management could provide. Compared with the other two categories, good candidates were older, prescribed more medications, and had more outpatient visits in the prior year. For patients who were good candidates, the number of hospital and emergency department admissions were greater than among patients who did not need care management and less than for the group needing more. Their analysis found electronic medical record data identified patients who were good candidates for care management. Maria E. Garcia et al., “Which Complex Patients School Be Referred for Intensive Care Management? A Mixed-Methods Analysis,” Journal of General Internal Medicine 33, no. 9 (Sept. 2018): 1454–60.

 

Study Finds Equity‐Oriented Health Care Improves Health Outcomes

A study that sought to determine whether equity-oriented health care — that is, care that recognizes and strives to reduce the effects of income inequality and discrimination — leads to improvements in patients’ health outcomes found higher levels of equity-oriented health care predicted greater patient comfort and confidence in the care patients received. This led to greater confidence in preventing and managing their health problems, which, in turn, improved health outcomes. The researchers surveyed patients recruited from four primary care clinics in Canada to determine whether their perceptions of equity-oriented health care led to improvements in self-reported health outcomes including quality of life, chronic pain disability, and post-traumatic stress and depressive symptoms. The researchers also found financial strain and experiences of discrimination had significant negative effects on health outcomes. Marilyn Ford-Gilboe et al., “How Equity-Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy,” Milbank Quarterly 96, no. 4 (Oct. 2018): 1–37.

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Editorial Board, December 2018

Special thanks to Editorial Advisory Board member Anne-Marie J. Audet, M.D., M.Sc. for her help with this issue.

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado

Michael Chernew, Ph.D., professor of health policy, Harvard Medical School

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, Rand Corp.

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Lauren Murray, director of consumer engagement and community outreach, National Partnership for Women & Families

Kathleen Nolan, managing principal, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., associate professor of family and community medicine, UCSF School of Medicine

James Pelegano, M.D., M.S., assistant professor of healthcare quality and safety, Thomas Jefferson University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, director of quality and operations support, The Permanente Medical Group

Stephen Somers, Ph.D., president and CEO of Center for Health Care Strategies

Mark A. Zezza, vice president, Lewin Group

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