EXECUTIVE SUMMARY
Health inequity and barriers can negatively affect patient care. Case managers can work with community organizations to untangle this societal problem.
- Reducing healthcare disparities requires a multipronged and collaborative approach in which case managers and health systems work with community-based organizations.
- One model uses a health equity team to collect data and focus on equity issues in small, targeted communities and populations.
- Solutions to healthcare disparities must be research- and data-driven.
Some healthcare organizations are shifting focus to healthcare access barriers that prevent certain patient populations from achieving optimal outcomes.
These barriers include meeting basic needs for food, medicine, safe housing, and transportation, says Willow Yerxa, MSW, director of mental health and case management for Health Equity Alliance (HEAL) in Ellsworth, ME.
“If we can meet those basic needs, we have taken a step to make the playing field just a little more level,” Yerxa says. “We cannot eliminate the disparities, but we can minimize the impact of them on their health and access to healthcare.”
HEAL was founded as an AIDS service organization in the 1980s, serving a population of people who experienced significant health disparities, Yerxa notes.
“They face significant stigma and marginalization, and we can see how their health is impacted by that,” she says. (See story about case management with a stigmatized population in this issue.)
Healthcare disparities and inequity, like income inequality, is a broad issue that requires multipronged societal action and policy changes to resolve. But case managers and healthcare organizations can make small changes.
For instance, Cedars-Sinai Health System in Los Angeles employs a health equity team that focuses on local issues, such as the high cancer mortality rate among Korean Americans and the growing number of liver cancer cases in the Hispanic community.
“Cancer centers take their knowledge, best practices, and research-driven outreach to neighborhoods of high need, and that’s exactly what we’re doing,” says Zul Surani, associate director of the Research Center for Health Equity at Cedars-Sinai Health System.
“We collaborate with our community outreach team to identify neighborhoods where populations are disproportionately burdened by cancer,” Surani says.
“We’ve identified neighborhoods with higher proportions of late-stage diagnosis breast cancer, and the predominant populations are Korean and Hispanic/Latino,” he adds. “We take evidence-based, science-based approaches recommended by the CDC, and we use a form of case management and culturally tailored information and navigation to work with the populations.”
Community-based outreach coordinators, navigators, and health promoters guide eligible patients to screening resources in their neighborhoods, such as federally qualified health center that offers free or low-cost mammograms, Surani explains. This focus on neighborhoods with health inequities is an investment with multiple layers of positive outcomes.
“It has increased people’s motivation and intent to get screened,” Surani says. “However, we have identified gaps in the system, in our navigation. Even though people may be motivated to get screened, there needs to be clear support for individuals — especially uninsured people — to get into the local clinic, where they can get free or low-cost cancer screening.”
This shows the organization what it needs to build. For instance, Cedars-Sinai has brought together stakeholders, including providers and clinics, to think about ways to improve health access, he says.
“This is research-driven outreach,” Surani says. “We’re looking at data constantly to make sure we’re being responsive.”
Case managers will fail at addressing health inequity unless they understand the population that lacks access to care, Yerxa says.
“It’s about creating spaces and opportunities for connection, understanding, and belonging,” she explains. “We know the lack of human connection and support absolutely impact both emotional and physical health outcomes.”
Yerxa and Surani offer these suggestions for improving health equity:
• Embrace data and details. Epidemiological cancer trend data, broken down to the community/ethnic level, can identify high-risk populations and areas.
The program at Cedars-Sinai collects neighborhood-level data, which is very useful for identifying barriers and finding solutions, Surani notes.
“We’re lucky that the cancer surveillance unit is providing data to us in terms of diagnostic areas,” Surani says. “It helps us prioritize specific neighborhoods where the need is high.”
Case managers can use these data to collect information that might answer the question of why residents of certain neighborhoods are not getting screened, he says.
• Employ “cells to society” model. “When you identify populations with a heavy cancer burden, there’s a multipronged approach that could be taken from neighborhood interventions,” Surani says.
The idea is to make a difference with high-risk populations and locations, he says.
“We are customizing interventions, doing those types of things in order to make a difference,” Surani explains. “We’re looking at creating a seamless system of care for communities that are most affected.”
Sometimes, solutions to health inequity can come from the patients affected by disparities.
“People who use our services are the ones offering up the most innovative ways of doing the work, of breaking down the health disparities facing our clients,” Yerxa says.
• Educate stakeholders. “We start with personal interaction,” Yerxa says. “Even when case managers call about major health issues, it’s hard to get a doctor on the phone. We start with a personal call, reaching out personally.”
Providers are not always aware of the healthcare barriers their patients face. Case managers can talk about these issues with patients’ doctors.
Advocacy and education also are used at health conferences, individual and agency trainings, and through legislative actions, Yerxa says. People who are affected by health inequities can be part of advocacy and education, speaking at conferences or to groups of healthcare providers and community leaders, she suggests.
“This gives people the opportunity to give back and make a positive change,” Yerxa says. “They are the experts, and we learn from them every day about how to do a better job at reaching and caring for others facing the same stigma and marginalization.”
• Create a team and take action. Case managers can join a team of providers and community organizations that work to identify opportunities for improving health equity.
“The team occasionally leverages resources available at Cedars-Sinai, so we have a lot of nurses who support our outreach efforts,” Surani says. “We also work with physicians within our system, bringing together a team that is truly responsive to the needs of the community vs. thinking one size fits all when we know it doesn’t.”
Cedars-Sinai also has included community outreach coordinators on its team. For example, Filipino nurses on the team support the outreach efforts and help conduct surveys in the Filipino community, which experiences higher rates of breast cancer, he adds.
The team also has partnered with two Korean churches and Korean clinics. “We have a Korean outreach coordinator who is working to develop a lot of this information in the Korean language,” Surani says. “I work with her to talk to the leadership in the different churches to think about how we want to develop this programming.”
They worked with leaders, doctors, and others to develop an education series. The outreach coordinator led the workshops, presenting information on cancer prevention.
“We’ll continue this series of workshops in different churches — we’ve proven it works,” Surani says. “Our outreach workers, often on Sundays, set up a booth and sign people up for the workshops.”
Programs to alleviate health disparities should be evidence-based and tailored to the particular community’s issues, he notes. The Cedars-Sinai program works with Latino, Korean, Filipino, African American, and LGBTQ communities to address disparities.
“We’re using programs that already have been proven effective,” Surani says. “We look at culture, literacy levels, and we’ve initiated a faith-based approach, where we could reach our target population multiple times to impact health behavior.”
A health equity team can identify communication and navigation gaps in the system and develop methods to close those gaps.
“Down the line, we will design large-scale interventions with our research teams to address these disparities,” Surani says. “We’re not just serving our patients — we’re going beyond our patients.”
Health inequity and barriers can negatively affect patient care. Case managers can work with community organizations to untangle this societal problem.
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