Fighting Healthcare Disparities | Health Equity and Stroke Prevention

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI, the most trusted voice in healthcare, committed to advancing effective, evidence- based care. I'm your host, Paul Anderson, and for more than 10 years, I've overseen our patient safety, risk, and quality membership programs here at ECRI. Tens of thousands of healthcare leaders rely on us as an independent, trusted authority to improve the safety, quality, and cost effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes www. ECRI. org. Today's episode is part of a series we're recording for the ECRI and the ISMP patient safety organizations' Deep Dive Report. This year's Deep Dive focuses on issues of racial and ethnic disparities in healthcare. And we're talking to our PSO members and others to hear about their initiatives to fight these disparities. Our guests today are from Thomas Jefferson University Hospital, serving Pennsylvania, Southern New Jersey and Delaware, and the Frazier Family Coalition for Stroke Education and Prevention that focuses its work on helping the community in North Philadelphia. They'll discuss an initiative advancing health equity and stroke prevention through collaboration conducted by the Philadelphia Collaborative for Health Equity and the Frazier Stroke Coalition in partnership with Thomas Jefferson University Hospital and Temple Hospital. We'll talk about how the collaborative's mission is to leverage health as a catalyst to help Philadelphians reach their full potential by addressing the drivers of health and health outcomes, and how these efforts fit into larger programs to fight inequities. So to get us started, I'll ask our two guests to introduce themselves.

Dr. Sandra Brooks: Hi. Thank you for allowing us to be here today. My name is Dr. Sandra Brooks, and I'm a gynecologic oncologist by training, with decades' long experience working with communities and health systems to advance health equity. I'm the chief medical officer of the Center City Division of Thomas Jefferson University, Hospitals, and also the executive vice president and chief community health equity officer.

Dr. Neva White: My name is Dr. Neva White and I am the executive director of the Frazier Family Coalition for Stroke Education and Prevention. My background is a nurse practitioner, and I have been here at Jefferson for about 21 years.

Paul Anderson: So Dr. Brooks, we'll talk in a second about the collaborative for health equity, but first I wonder if you can help us set the stage a little bit. I mentioned in the introduction that Jefferson serves patients in Pennsylvania, New Jersey, Delaware. Can you describe a little bit more about the area that you serve, the patients that you serve, and importantly for today's conversation, some of the major barriers to equity that you see?

Dr. Sandra Brooks: Certainly. So you may be aware that Jefferson Health expanded from a 3- hospital system, just about a little bit more than a decade ago, to now out what is a 14- hospital health system, and will soon be an 18- hospital health system. Clearly quite a large footprint. The area that we're focusing on today is the Philadelphia region, and specifically North Philadelphia region with the zip codes of 19121, 19133, 32, and 19140. And the reason we have aim to focus on those zip codes, and the reason we're looking specifically at cardiovascular disease is because we know that cardiovascular disease accounts for about 24%, nearly a quarter of the total deaths in the city of Philadelphia. And we know that there's wide disparities and outcomes between those individuals that live in those specific zip codes compared to zip codes just about two to three miles away. So really, we're aiming to focus on the area where they're the greatest disparities, but we know that when we work in partnership with our communities, we will develop understandings and collaborations and know more about what works so that we can apply those learnings to our other populations as well.

Paul Anderson: So, an you describe a little bit about some of the real barriers to equity that you see, maybe particularly in those zip codes that you just mentioned?

Dr. Sandra Brooks: Right. I mean, and health equity has been amplified this past year. And the drivers of health equity have been amplified by the pandemic, but these issues have been longstanding and are complex. So if you think about the CDC pyramid that talks about the drivers of health, at the base of that pyramid, which has the largest impact, are those things such as poverty, education, housing, structural racism. And these are things that we know, that given decades of policies that have disproportionately disadvantaged Black and brown communities, specifically African Americans, that have led to concentrated poverty in a number of areas, you can draw almost a direct line to areas that were redlined back at the turn of the century, and how poverty has become concentrated in those areas. So we know that that's the largest driver. And then you go to the next level of the pyramid that relates to policies, public policies. So recently, our Department of Health has mandated healthcare workers become vaccinated. That's the example of the type of policy that can drive and reduce health disparities. So other things such as immunizations, what we've been talking about with the COVID- 19 vaccination, interventions that can be done. At the top of the pyramid are where a lot of healthcare systems sit, clinical interventions, counseling, and education. So what we're aiming to do with the Philadelphia Collaborative for Health Equity, and specifically the Frazier Coalition, we're aiming to address each part of that pyramid in order to be able to narrow the gap in health disparities.

Paul Anderson: And before, you mentioned the Frazier Coalition, and Dr. White, I'm going to bring you in, in just a moment, but I wonder if we can... What's been really interesting to me as we've talked to some folks is something that you just pointed out. You said in a previous conversation that we had leading up to today, a person's race and zip code should not play a major factor in determining their likelihood of surviving any number of chronic or acute conditions. But we know that is the reality we're living in. And it's been really interesting to me to see healthcare providers try to move down that pyramid that you just described because as you said, most of them maybe are sitting at the top, focusing only on clinical interventions. As you came at this problem, was there a point where you can look to and say," Okay, I really know now that there is a role for the healthcare provider organization to try to get at these things that maybe historically we've thought are sort of out of our lane, right?" That's a public policy thing. That's not a healthcare thing. Was there a place where you can point to and say," No, no, this is a place for healthcare to be involved?"

Dr. Sandra Brooks: Right. And I think there clearly have been a great precedent of people involved, not only in healthcare, but also in public health, who've recognized that these are the drivers of health. I think that the challenge has been what tools do we have at our disposal to address those drivers? So a number of your listeners are very clearly deeply steeped in quality and safety work. So if we're aiming to reduce mortality, or reduce admissions, or reduce adverse events in the hospital, if our patients are coming to us at a very advanced stage of where they haven't had access to screening or primary care, the amount that the health system is going to be able to intervene and reverse that course, we recognize. Now we have the data. We can see. But I think that with the evolution is the understanding that we not only have to capture race and ethnicity, but we also have to capture wider, actionable items. So is education, is there health literacy component? Does the person have social support at home? Does the person have access to a primary care physician? Is the person able to communicate? Are we able to communicate with that person in the language that they feel most comfortable? So I think with greater access to data, greater ability and depth of understanding of what drives some of the disparities, we can move beyond categorizing race as the driver. So we know that if we have 10 factors that we know drive health, and we're able to measure those factors, but now we still see a delta. Now we might make the assumption that that delta might be the structural policies, or might be bias that is involved. But until we have a greater understanding of all of those other factors, I think it's really shortsighted for us to solely look at race and ethnicity because really what of that is actionable? So I think that for those, we definitely need to develop a greater cultural sensitivity and awareness. I think our ability to do social determinants of health screenings are helping us to get there, our ability to do implicit bias training, ability to make sure that we have a diverse and trained workforce. All of those things will help us to get closer to our end goal of making sure that we're understanding the perspective that that patient or that individual comes to us with and help to be able to meet their needs in a more holistic way than we have in the past.

Paul Anderson: So Dr. White, I'd like to sort of talk a little bit now specifically about the Frazier Coalition and narrow in on one area we're working on, which is on reducing the risk of stroke. So I wonder if you could tell me a little bit about the coalition, the initiative that we're talking about, and in particular, what are some of the things that the coalition is leading on to reduce the risk of stroke for the affected population?

Dr. Neva White: Yeah. So the Frazier Family Coalition for Stroke Education and Prevention is made possible through a gift from Andréa and Kenneth Frazier. Mr. Frazier was born and raised in this community, so this is really a full- circle moment for the community, being able to have an individual who was born and raised in this community, and now giving back to the community. The other very important aspect of this program is that we're working with two major health systems. So we're harnessing the resources of Jefferson Health as well as Temple Health. And we really want to target stroke risk factors for prevention. So we want to do it from a chronic disease self- management perspective. So our programming is really focusing on how we can help people to better manage their hypertension, better manage their diabetes, prevent diabetes, weight loss, and doing that in conjunction with providers, so to be a clinical support, if you will. Then, our team of community health workers are serving as credible messengers in the community, so they can directly address social determinants of health and really build these networks so that we can just not only give people information, but we have a direct connect to these organizations that we're working with so that we can put a face with a name and sort of understand what that process is going to be when we introduce people into these services. The other thing is that we really want to build on our existing community relationships. I mean, we have so many years of experience, both health systems. How can we build on those relationships because we know that we can't do this alone, and how we can work together to really look at reducing stroke in North Philadelphia.

Paul Anderson: How important are those relationships? Because I've heard this from some other folks too, to have those existing, in- the- community relationships. How important is that to be building on those, as opposed to say, if you parachuted in and we're starting from scratch?

Dr. Neva White: Well, when you look at community organizations, the history, the history that they have in the community, and in many cases, residents from the community actually work and live right there. So building community trust and getting to people that we may not traditionally be able to through some of our current marketing strategies, really getting almost like a block- by- block outreach, if you will, into the heart of the community, and also to be able hear the community voice in a way that it can be heard because many times people, they have issues, they have problems, but getting that information out in a way that it can be understood and that we can move on it is very important. And our community organizations have been doing that for so long.

Dr. Sandra Brooks: And Dr. White has raised on a very important point that in a lot of this work, we need to work with trusted messengers. And if you just even take the vaccination efforts as an example, oftentimes, there's so many ways that people can get information, it can become overwhelming. And we know that there can be a lot of mythology out there or disinformation. And working through trusted messengers is a very valuable way to be able... It's bilateral. It's not only we're providing information to people because we have all the answers. We need to hear from the community about what the community needs and how the messages resonate with them so that we can develop a strategy that's maximally effective.

Paul Anderson: Yeah. Again, that makes a lot of sense to me. And it's something we've heard from other folks. And I guess sort of to me, the next logical follow- on from that then is, well, if I'm an organization, as you described earlier, Dr. Brooks, that is only sitting at the top of that pyramid, and is not maybe as deeply embedded in the community as they need to be to have those conversations effectively and to listen as well as they're speaking, is it fair to say that they need to start immediately, right now, yesterday in identifying those folks and building those relationships and starting to sink those roots in, if they haven't done it yet because maybe it's not going to help next week, but it's going to help a year, 5 years, 10 years from now when whatever God awful thing we're dealing with in 10 years, that they have taken the time to build up those roots and communities?

Dr. Sandra Brooks: Absolutely. And I think sometimes what it means is connecting the dots. So for a lot of nonprofit health systems, they really are already doing work in the community that helps them to maintain their nonprofit status. But that work may or may not align with this strategic objectives or priorities of the quality and safety program or of the hospital operations. And so part of this is to try to look at the resources that you have, look at the scope of what you're trying to achieve, and try to align those resources so that you can be maximally effective. And also there's not a small part of this that means being humble. Be willing to admit that perhaps the approach you've taken in the past has not been the best one. But there are a lot of innovative things that are going on, collaborations with federally qualified health centers that have really been doing this work for decades, working with well- respected community organizations that represent very diverse populations. And so I think the substrate, the ingredients are there. You just really need to have the right recipe, but recognizing that it's an iterative process.

Dr. Neva White: And if I could just add to that, we have a community advisory group and it's a very diverse group. We've got probably about 25 organizations and residents represented. And I'll tell you, it's, it's been invaluable because even in how we define the community, Philadelphia is a lot of neighborhoods. So people are very particular as to how you address their neighborhood. So having that insight from our advisory group and just how we may have an idea of how we want to approach a particular topic, or how we want to reach out to people, our community advisory group automatically tells us whether or not they think that's a good idea or not.

Paul Anderson: Yeah, that makes a lot of sense. And I think that's all related to, Dr. Brooks, a phrase that you've used before. And I think this sort of also touches on something that you were describing earlier, but it's that idea of a health ecosystem. So it's not just the immediate presenting clinical concern, but I wonder if you could explain a little bit more, what you mean when you describe that idea of a health ecosystem and how addressing that is part of the larger initiative, again, to get back to our theme, to try to be fighting against these disparities and inequities?

Dr. Sandra Brooks: I think that part of this, again, if we think about if the ultimate goal is to provide for a health system, probably as Dr. Klasko says, is maybe considered a misnomer because in acute care hospitals, we're taking care of people who are not healthy, who've come to us with a particular condition. So the health ecosystem, as it has existed for some time, has really rewarded or incentivized health systems to take care of very sick people and has had less emphasis on how can we prevent people from becoming sick in the first place. And I think there's obviously growing recognition, emphasis, and support for advancing those things that help to prevent people from getting quite so ill in the first place. And so a recognition that it's not only building bigger and better, but also providing support through patient navigation, through community health outreach workers, through having the infrastructure to assess the social determinants of health and be able to navigate people to the resources they might need to either have access to medicine, to have access to safe housing, to have access to heat in the winter, or to healthy, nutritious meals. So, we're not there yet, but I think that a more responsive ecosystem recognizes that in order to make a significant... Health quality and safety do not necessarily accordingly equate with equity. And so I think we recognize that we need to have a more holistic strategy in order to truly approach health equity and to achieve the safety and quality that we really aim to have for our communities. Does that sort of help to provide?

Paul Anderson: Yeah, very much so. Before we move on, there are a couple other things I want to ask about, but Dr. White, I don't want to forget to ask you about the role of the Collaborative for Health Equity that interfaces then with the Frazier Family Coalition for Stroke Education and Prevention. So can you tell me about the collaborative and how sort of all that fits together?

Dr. Neva White: So the Philadelphia Collaborative for Health Equity is really our overarching community outreach, community health hub for Jefferson Health, and it directly supports the work of the Frazier Family Coalition. So it's our overarching, if you will, look at health equity by design and from a systems approach, really looking at those upstream factors when we talk about health equity, so we have the Philadelphia Collaborative Health Equity at the top, and then Frazier Family Coalition is one of those initiatives.

Dr. Sandra Brooks: So if I could amplify on that as well, I would say we're looking at the work of the Philadelphia Collaborative for Health Equity in about four different buckets. One would be considered that capacity building, where we work with community organizations, amplify the work that they do. So whether it might be a group that's working with teenagers on trauma- informed care and helping to develop resilience. It might be a work just helping to make a neighborhood safer in some way, or helping to connect people to mental health services or trauma prevention. We also conduct trainings. We're looking into how we can improve digital access. So that would be an example of capacity building. Another example would be that tangible infrastructure where we would have a very defined program. Like the Frazier Family Coalition, or we have a health center in South Philadelphia, which is serving a very diverse community that has a large percentage of immigrants, and is really designed to be so welcoming to that community. Another area would be the clinical preventive outreach things that we do in the community related to screenings, where we are really aiming to work with our community health outreach workers and our community- based folks to help to navigate people to care. And then the other area would be our policy piece where we're working and collaborating with a number of nonprofits and governmental agencies to really look very upstream at how we help to promote policies. An example would be community health workers. It's a field that people can come through from a variety of other fields, or people who just live in a community who really very much, very passionate about their community who want to be able to help. We look at them as the connectors, but yet it's been a challenge to make sure we have the type of training and really have certification that's recognized, that people get paid adequately, and that there's a career ladder. So all of those things require policies. So again, that's an area where we're not only helping the healthcare community and helping the people in the community, we're also providing valuable work and improving workforce development.

Paul Anderson: Dr. White, sort of mindful that we're recording this in the late summer, early fall of 2021. So we've been at this pandemic thing for about a year and a half now. How has that impacted the work you do through the Frazier Family Coalition, both the stroke, both the specific thing, but more broadly, how has that impacted all of it? I don't know how else to say it, just all of it.

Dr. Neva White: Yeah. So interestingly enough, in 2016, we really started to look at distance learning because we saw other barriers that people had in terms of getting on the bus, childcare, and all these things. So we started creating a distance learning platform way back. So we were well- positioned for the pandemic to move everything to an online platform. However, we still struggle because we know that many people, there is a significant digital divide, and many people still don't have access to the internet. People don't have some of the skills that they need to navigate the internet. So we're working very closely with individuals to help them to get the tools that they need, not only get the tools, but know how to use them and feel comfortable in using them. And the other thing that we're really trying to promote is access to telehealth because we know that many people at the heart of the pandemic, I guess, is the best way to say it, did not go to see a provider because they were afraid. And many of them were not in a position to even access telehealth. So we really want to promote that opportunity for people to feel comfortable with that, feel comfortable with learning online, and being able to share that space. One of the things that really was exciting for us, and this was early on in the pandemic, when we were having our diabetes prevention programs online, we found that it was a source of support, particularly when it was a lot of social unrest around March, April, 2020. We really found that by having that place to go, people felt comfortable in connecting because many people were isolated. So being able to get on a Zoom call with 20 other people, just to kind of feel like you weren't alone. So we want to kind of preserve that feeling and that safe space for people in this sort of virtual learning environment.

Paul Anderson: And then Dr. Brooks, one last thing I wanted to sort of pull on a thread you raised very early on in our conversation was about COVID- 19 vaccination. And obviously, that's been, again, we've had vaccines available for 9, 10 months now, and it's been a huge source of concern about hesitancy and the inequity in the rollout of the vaccine. And how do we do this combination of convincing folks to get vaccinated, but also make sure it's available in a way that they can receive it. And if we need a second dose, that follow up can be such a challenge for all same reasons that any kind of follow up care is a challenge. So I wonder if you could talk a little bit about some of what you and your team at Jefferson have done to try to really increase access and availability. I mean, not availability, but to increase access to the vaccine and to reduce hesitancy wherever we can.

Dr. Sandra Brooks: Right. So, it has been definitely an evolution. So in the beginning, when the vaccines were somewhat scarce and the eligibility was being rolled out, we recognized that there were some inherent potential inequities in that rollout. So we recognized that African Americans were disproportionately more likely to be hospitalized or be in the ICU or die from COVID- 19. But yet, the original rollout was for people 75 and above. We recognized, well, if the average age of life expectancy of an African American is 68, who's going to be in that initial population? So we were able to utilize our access to patients who were enrolled in MyChart, and to be able to look at and be able to make those invitations more equitable with a bit of an oversampling based on the risk of the population. And we also recognize that MyChart, which is those folks who had access to EHR and their records on the electronic health record might also be a subset of people. We also, in parallel, had to develop a more boots- on- the- ground approach of inviting people to become vaccinated. We also conducted dozens and dozens and dozens of what we call real- talk, trusted- messenger trainings, and did that through faith- based organizations, through nonprofit organizations, schools, retirement associations, civic neighborhood associations, SEPTA. So a variety of folks to be able to help, to provide real talk, to really directly confront the things that people were concerned about or what they professed that they were concerned about and try to provide some very common sense, plain- talk language about what was factual and in an empathetic way. And we were successful in really accelerating the uptake of vaccination with that approach over time. And we had to do a number of one- on- one. We worked with the the folks who were previously census takers, who went door to door. We did some trainings because they were then converted into people who were going door to door to talk to people in different languages. So we conducted those trainings in multiple languages. And so we were proud to work with Department of Health. We also had a group of very dedicated mobile vaccination folks who partnered with Department of Health to create popup vaccinations. Just this past two weeks, we had a mobile vaccine party where we did a parade down Broad Street, stopped the City Hall, created a lot of constructive commotion to raise the signal to noise about being able to vaccinate people. Just come in you. And we have gotten better at how we make sure we have people have a follow- up appointment. And so we've gotten better, developed more robust tracking so that we make sure that people get their follow- up as well. And most recently now with the FDA approval and with the changes in the guidelines for the city, and with more and more health systems and organizations requiring vaccination, and then venues, quite frankly, requiring vaccination, or to be able to have access to different venues, we know that the folks who currently are not vaccinated, it's a bit more of a challenge to get to that last mile. But we're continuing to be persistent and we're conducting town halls in our hospital morning, noon, and night to be able to make sure that people have access to up- to- date information.

Paul Anderson: That training you mentioned is so interesting to me because it occurs to me that those folks who are the trusted messengers, you mentioned they're from faith organizations, you mentioned SEPTA, which is our local regional transit. All those different places, they may be trusted messengers, but they are probably not virologists or immune disease experts. So giving them the information they need to answer the questions to have like both accurate information, but also information that will meet that health literacy goal as well, that's really interesting to me.

Dr. Sandra Brooks: And to put it into context because there's a lot of information out there, but it's not all in context. So if people hear about an adverse reaction, well, let's talk about context because the severity of COVID- 19 illness in the unvaccinated far outweighs the risk or the severity of a side effect that the vast, vast majority of people will experience. So really provide that context to people.

Paul Anderson: So as we wrap up, I'm going to ask you each to do something that's maybe a little unfair, but I always like to ask people to say, okay, what's the first step. These are huge initiatives we're talking about. We're not going to solve all these problems in an hour or in a day, but we've got to start somewhere. So if I'm in an organization that maybe has not built the kinds of coalitions and relationships that you're talking about, but I want to, and I'm leading a hospital system, an individual hospital, whatever, where do I start? What's my first step? And, Dr. Brooks, I'll ask you to go first and then Dr. White.

Dr. Sandra Brooks: Sure. I would say that for an individual, they should at their span of influence and look at how could they examine health equity? How can they look at what they're doing from a health equity lens in their span of influence? How do they represent that perspective in every meeting, every task force, every policy group, every committee, how can they do that? And when we're preparing and looking at implementing a policy, understanding how that might either help or hinder advancing our health equity. And I think the vaccine invitations is one huge example. And when we initially had the initial discussions, that health equity lens wasn't quite there. And there are a number of us who raised our hand and said," No, we got to look at this differently. Or we will wind up down the line with a process that was not intentionally unfair, but in effect was unfair." So I think that's the first thing. The other thing is to take an asset map, look at who's doing this work in your institution and look at how you might help. How can you be an ally? How can you show up? I think looking at how who's involved in the work that you're doing that does interface with the community, does that represent the community? And I think that's extremely important because if those voices are not there, that perspective won't be there. In your own sphere, vote, join, become involved, be part of your community, be a person who like seeks to get information in a balanced way. Join a council. And on a personal level, help a neighbor or an elderly person in your community. If someone's having difficulty, I sort of get nominated as the navigator for my extended family. And it's a burden that I take on willingly because I think the health system is so complicated and it does help for people to have a person that they trust that can help them navigate situations. So that's kind of how I would look at it.

Paul Anderson: Dr. White?

Dr. Neva White: I would say that we need to really think about cultural competence and cultural humility. We're living in very interesting times, and a healing approach to our work is very critical. And allowing the people that we serve to really have a say in the interventions and how we work with them because listening to people and really understanding the reason why they're not doing something is just as important as the reasons that they are doing things. And sometimes it's just that it's things, the way I've been doing this all along in my traditions and my way of thinking, these are valid. These are valid things. But to embrace those things and allow people to even use some of the trauma that they've gone through, I mean, many of us have experienced direct and indirect trauma in just last year or so, losing loved ones and friends to this pandemic. And there's a lot of fear. Some of it's historical fear. Some of it's real fear. And some of it could be false fear, but it is what it is. And I think embracing that and using that to guide us and to really help us to understand the human condition, and just what we feel ourselves and what we're experiencing ourselves because we're still in this. We aren't out of this, and there's more to come. So just being a little bit humble and healing towards one another.

Paul Anderson: Well, I think that's a great place to, to wrap up. I think that's good advice for a lot of things, but especially for the topic we're talking about today. So as I say, we'll leave it there. So Dr. Brooks, Dr. White, thank you both so much for joining us.

Dr. Neva White: Thank you.

Dr. Sandra Brooks: Thank you. It's been a pleasure, appreciate it.

Paul Anderson: You can learn more about ECRI and the ISMP, PSO from the ECRI website at www. ECRI. org, where you'll also find our 2021 Top 10 Patient Safety Concerns Report, which features racial and ethnic disparities in care as the top issue. You can find out more about Thomas Jefferson University and the Frazier Family Coalition for Stroke Education and Prevention through hospitals. jefferson. edu. Be sure to subscribe to Smart Healthcare Safety on Spotify, iTunes, Google Play, or wherever you get your podcasts to get our latest episodes. We welcome your feedback. Visit us ECRI. org, or email us at ECRI- Podcasts @ ecri. org.