Fighting Healthcare Disparities | Person-Centered Care Programs

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 at www. ecri. org. Today's episode is part of a series we're recording for the ECRI and the ISMP Patient Safety Organization's Deep Dive report. This year's Deep Dive focuses on issues of racial and ethnic disparities in care. And we're talking to PSO members and others to hear about their initiatives to fight against these disparities. Our guests today are from the Camden Coalition of Healthcare Providers, serving Camden, New Jersey residents to improve the lives of people with complex health and social needs. The Camden Coalition also works to help patients across the country through the coalition's National Center for Complex Health and Social Needs. We'll talk about how the coalition's mission is to improve care for people with complex health and social needs by implementing person- centered care programs, that address not only illness, but also strive to overcome social barriers to health and enhance wellbeing. So to get a started, I will ask our two guests to introduce themselves.

Kathleen Noonan: Great. Thanks, Paul. This is Kathleen Noonan. I'm the CEO of the Camden Coalition, and we're really happy to be here.

Natasha Dravid: Hi, Paul I'm Natasha Dravid. I'm our Senior Director of Clinical Redesign Initiatives at the Camden Coalition.

Paul Anderson: Kathleen, I'd like to start with you. We're going to talk in a little bit about the Camden Delivers initiative specifically. But let's maybe take a step back from that. If you could help set the stage a little bit. You're set in Camden, New Jersey. So I wonder if you could tell us a little bit about Camden, a little bit about your patients, and importantly, some of the major barriers to equity that you see among those patients.

Kathleen Noonan: Sure, absolutely. And just one step back, I'll say that I came into Camden having spent 10 years at the Children's Hospital of Philadelphia, which is right across the river in Philadelphia. And I'll say that I had a very big system hospital centric, if you will, view of these issues. And coming into Camden was a challenge because we were thinking about some of the same issues, but from a small community- based organization's perspective. So Camden, New Jersey, is a small city across the river from Philadelphia. Imagine the twin cities of St. Paul and Minneapolis, we are Philadelphia and Camden. Camden roots for the Philadelphia sports teams.

Paul Anderson: That's why we had you on, I didn't want to say anything.

Kathleen Noonan: Exactly. And Camden is small. It's about 75, 000 people in the city. About half of them are of Latinx or Hispanic origin, and half are African American. There is a small Asian American community, but the city is pretty much, you could say, non- white. The city is in a county that has over 200,000 people. And then in really an area of south Jersey that is well over a million people. Even though we're a small city, we're next to a very big city, and so we have that metropolitan feel, if you will. Camden was once a thriving RCA town, a thriving middle class place, and really fell the way a lot of industrial cities fell in terms of losing jobs and white flight. And is grappling with that today with high poverty levels, many, many, many people who are working, but are working jobs that do not allow them to live in a way that can keep them healthy. And just some of the same problems that you see in a lot of urban areas, but unlike a big city like New York where they're very very wealthy and very very poor Camden doesn't really have that contrast at all.

Paul Anderson: Thinking about that population you described Kathleen, and a lot of the social barriers, I'll say, that really face the patients and the folks in that population, how does that play then into a health equity perspective and maybe some barriers that those folks face in trying to access care?

Kathleen Noonan: It smacks right into it. But since we started... the Camden Coalition started in 2010, I would say, that we started our care management work in a pretty organized non- pilot way, starting in 2007. And pretty much from the get- go, we had an interdisciplinary community- based team, nurse, community health worker, social worker. And from the get- go, we actually saw health as just one of 16 domains that a person might want to work on to improve their own wellbeing. And so we put those domains in front of them and talked about that because we realized that there could be issues around housing or legal issues or food issues, any of those issues. Even though we were introduced to people through a pretty traditional health issue, we knew because of the so much structural racism, so much structural inequity, that we had to really think about the other things in their life and work them on what was the most important thing for them to fix, to start, to be able to go down the road of getting healthier.

Paul Anderson: And then I know that the coalition in particular has, I'll say, reach beyond Camden, and even beyond the region that you described of south Jersey and into Southeastern Pennsylvania. Can you describe a little bit some of the more national reach and the national programs that the coalition has?

Kathleen Noonan: Sure. In 2016, we were lucky enough to get funding from the Robert Wood Johnson Foundation, ARP was an early sponsor. And the idea was that we were doing this work in Camden, but we knew that there were colleagues, peers, community- based organizations all over the country that were doing the work that we were doing. And so the idea was to create a home for that work called the National Center for Complex Health and Social Needs, and gather annually through a conference, but all through also through the national center be able to dispatch people, either from the coalition, who had worked at the coalition directly on the ground here, or other people who we recruited in, who worked in similar programs, but perhaps their focus might have been in a rural setting or in a suburban setting and be able to dispatch them to other places around the country. So an example is Clearlake, California, Northern California, very rural, same issues as Camden in many many ways, but they manifest themselves differently. And just adapt some of the best practices from around the country to that type of setting. The key for us always is person- centered, it's always looking at health as just one domain and it's always interdisciplinary discipline with a small D, and also it's multisectoral. Those are the keys for us.

Paul Anderson: The name of the national center is the National Center for Complex Health and Social Needs. I've heard you in other conversations use the phrase of a complex care provider. Is that what you're talking about, that sort of multifactoral multidisciplinary?

Kathleen Noonan: Yeah. We are talking about that and we realize, I think the more we talk about it, the more we realize our clients, because we still have clients every day on the ground in Camden and the region that we deal with, in some ways the systems are much more complex than their issues. They come to us and it's pretty, I don't want to say simple, but what they need is in as hard to figure out as getting it. And the getting it is really hard because of the systems. And so that makes it complex. Being somebody that can navigate that, whether you are the consumer or you are the person trying to work with them, is really what brings the complexity to it.

Paul Anderson: And Natasha, I want to bring you into the conversation a little bit. One of the initiatives that I'm betting touches really on that, dealing with a complexity, is this idea of the clinical redesign program. I wonder if you could describe that program a little bit and what it means for those patients who are dealing with those complex health and social needs?

Natasha Dravid: Sure. So clinical redesign at the Camden Coalition was really born out of the work that we do directly with patients in the community. So as Kathleen described, we see these barriers that patients face over and over that aren't really about the patient, they're about the system. And they out how our healthcare providers and our social service providers deliver care and all of those systemic barriers that are part of the fabric of our community. So clinical redesign is about identifying those patterns in the barriers, and then working with our partners to reimagine and redesign the way care is delivered. So an example of that is one of our programs is the 7- Day pledge, was an initiative where we knew from our own data that individuals who were on Medicaid and going into the hospital, if we could connect them back to primary care within seven days, that would decrease their chances of being readmitted to the hospital. So we knew there were barriers in the way. There was access barriers, so not being able to get an appointment at primary care, transportation barriers, opportunity costs, not being able to get childcare or take a day off work. So clinical redesign was," Let's look at these barriers and systematically try to address them and do this at scale across our community." So clinical redesign is about working in partnership to redesign and get those barriers out of the way so patients can get the healthcare that they need at the right time and the right place.

Paul Anderson: So within that context of the clinical redesign, I know there's an initiative called the Safer Childbirth Cities initiative that the coalition leads. I don't know if you could describe a little bit about what that program is and who are some of the patients that it serves?

Natasha Dravid: Sure. Safer Childbirth Cities is an initiative designed to reconnect individuals or connect individuals to prenatal care. It's born out of the observation that many individuals are going to the emergency department early in their pregnancies, especially we've noticed this for or years in Camden city. And these individuals they're early in pregnancy, they find out that they're pregnant in the emergency room. They might be four or five, six weeks pregnant, but then we don't see them showing up in prenatal care within that first trimester. So Safer Childbirth Cities is an initiative to try to connect individuals to prenatal care in the first trimester. What we noticed is that there isn't a workflow in the emergency room right at the point of a positive pregnancy test to connect that person to prenatal care. So we have recruited sites across both our city and our region to launch outreach workflows where individuals will get a phone call to pull them into prenatal care as soon as we see in the data that somebody had a positive pregnancy test.

Paul Anderson: And so that must involve, I'm thinking, working not only with that outreach to pull the patient into the system, but also with providers throughout the region that they can actually get to, right? All those barriers that we talked about, access to care and transportation and everything. So that must be a really involved network.

Natasha Dravid: Yeah. We have and recruited all of the prenatal care providers in Camden city, as well as a couple of community- based organizations that run Central Intake, which those organizations house a lot of community- based programming for pregnant and parenting individuals. So those organizations are doing the outreach. It's not Camden Coalition staff doing outreach. It's actually coming from the OB offices or these CBOs. And everyone who gets a phone call to invite them into prenatal care is also getting offered a round trip transportation option, whether it's a taxi or an Uber to get them to that first appointment. And we're giving each site a patient costs budget that they can use however they see fit, to try to both get that person into care but also retain them in care. So whether it's some of our sites are doing different gifts at different points along, a gift at the first trimester, second trimester, third trimester, there might be an offer for some assistance with childcare and we're giving them flexibility on how to design that incentive program to get people hooked in and then retained in care.

Paul Anderson: That really speaks to that person- centered initiative," Let's see what this individual patient needs that will help them overcome their barriers, and let's react to that." That's great.

Kathleen Noonan: Paul, I'll just say, having come from a big hospital system, one of the things that surprises us at the Camden Coalition is that such a small amount of money like$ 10,000. And$10, 000 maybe means a lot to us as a small organization, but to these hospital systems, it's nothing. And yet, an OB practice within a major health system, having that, those kinds of flex dollars are so important to them and vital, and yet it's not something that is typical in their budgets. And so again and again we find our partners willing and excited to work with us. Part of that is because of some of the flexibility that we afford to them through the programs that we develop.

Paul Anderson: Well, that's interesting. And I want to tie that into something that Natasha mentioned, and Kathleen, maybe you can expand on this a little bit. Natasha mentioned that we see in the data that the patients have had a positive pregnancy test. And I'm wondering how you use maybe that data, but I'll say data more broadly, to structure the program and drive some of the initiatives. And I'm wondering then, to sort, tack onto the piece that you just mentioned, how you're able to track some of the programs that those providers are using with those flex dollars to see, is there something here that's particularly effective that we can then replicate and promote somewhere else. Or at least let other people know," Hey, this is something that has worked somewhere else. You may want to think about it."

Kathleen Noonan: We work pretty closely with our state's office of Medicaid innovation. And we are actually, we are designated what's called a regional health hub, which is a New Jersey statute, a designation where we receive Medicaid funding to among other things, do some data analysis, both for partners locally, but then also for the state. And one of the things that the state asked us to help them with was to look at pregnancies in our area and to understand the population that was delivering fee- for- service, that were not delivering through an MCO. And the question was, was this a population that was undocumented? And so they were coming in and they were always going to be fee- for- service births given the inability to be able to put them on a public insurance program. Or, were they people that really could be connected to an MCO and had they dropped off? And what we found was that there were many many more people who were connected to MCOs than we had thought. And so that was the data piece that helped us understand that there were people that were just dropping out as it were. That weren't getting prenatal care, that could be assigned to an MCO that have some care management responsibilities. And so targeting them. I think the other interesting thing, and Natasha you're closer to that data than I am, but we found that, by and large, undocumented people were more likely to go in and get prenatal care. They were here, they were here for a reason, they want their kids to do well. They were really doing what they could to get prenatal care. And so we take that data and then that's where Natasha's group says," Okay, how can we design an intervention that can help using this data, and with an eye towards replication?" So maybe Natasha I'll let you answer the replication part of that question.

Natasha Dravid: So the tool that we use to really operationalize some of this data- driven work is the health information exchange. And so through the HIE, we receive data from all of our local hospitals, as well as some outpatient data from our federally qualified healthcare centers. We get data from our local jail clinic. We get the Medicaid claims data pushed into our HIE as Kathleen mentioned. We get perinatal risk assessments, which is the tool that Medicaid uses anytime a woman enters prenatal care. And so we have this really sophisticated integrated data set that allows us to take data from these various sources and put it together, to have a holistic view of what's going on for a patient. But we can also use it to create real time population level views of what's happening at a community level. So we have a view every day of who's going to the hospital in the city of Camden. And we have clinical data points to tell us what are they going to the hospital for? We can slice that data on past diagnoses, what's going on today, and we can build workflows that are real time and actionable that our healthcare providers can use at the point of care, in that moment. So I think one of the ways through the regional health hub infrastructure that we're using this data, is, all four regional health hubs have these HIEs, these regional HIEs. So anything that one community develops in their HIE can be replicated to one of those other cities in New Jersey.

Paul Anderson: So you mentioned, Kathleen, that the coalition has been working for more than a decade now. But let's acknowledge we're recording this in late 2021. So the last year and a half- ish has been in COVID times, and I have to imagine that that has really upended a lot of things or at least changed them. So I wonder if you could talk a little bit about how COVID- 19 has impacted existing initiatives, maybe given rise to new initiatives? I'm thinking about maybe work with COVID positive, the homeless population, vaccine hesitancy, all these things that we've seen become such a big issue in the last 18 20 months.

Kathleen Noonan: A few things, and I'll ask Natasha to talk about a couple of those. In terms of upending, I think that we're in the boat where a lot of people in the health space, it's just constant. And I would say that we were already a community- focused provider so that our care teams were already community- based. So we already had a lot of mobility in how we worked. We thought always about how did you get data when you were at a homeless shelter or how did you get data when you were here or there? So we were positioned actually pretty well. Telehealth was not something that was hard for us because we would often have to talk to patients in the jail, for example. So for us, that was not a blip for us at all. We just kept moving. But it did actually for us point to some partnerships that we needed to strengthen. We really needed to strengthen partnerships with our county and city health folks. There's a way that you can be in a bit of a bubble in the health system and the community- based organization. And because of how poorly public health is financed in this country, the public health system is writing parallel to you. But not as much interaction as maybe now we all wish we had. And we certainly, if I look at us now and I look at us a year and a half ago, we are on... I say this, but we don't just know the leaders at the health department. We know the people working for them, and we know the nurses on the ground, and we know the people who are running their mobile units, and these are not new people. These are just people that we were working in parallel with and they were working in parallel with us. So I think that that is a great thing that has come out of COVID, and I don't see us going back. Because once you do that, you really understand that there needs to be more intersection between public health and healthcare. So that's one way that's been really useful. On the vaccine hesitancy side, we started very early before the vaccine was available to really think about hesitancy. And we've certainly canvas, we go door to door, we have ambassadors, we've developed pop- up clinics. But one thing that we've done that we don't hear too many people talking about that I'd love Natasha to talk about, is vaccine hesitancy, but not on the part of the people who need to be vaccinated, but on the people who have to ask people if they need a vaccination. We see tremendous hesitancy around that conversation. And so Natasha, why don't you talk a little bit about that?

Natasha Dravid: Sure. As Kathleen mentioned, in the fall of 2020, before the vaccines were even approved yet, we knew this was going to be an issue in our community. So we developed a survey, not a paper survey, but a conversation- based survey that we could have trusted community health workers, healthcare providers, individuals across the community, have conversations with the people they already had a relationship with to understand; what's your posture towards this upcoming vaccine? How likely are you to get it? How are you feeling about it? And so we were able to have 265 of these conversations across the region. We had a lot of really interesting findings, but the thing that really stood out to us, that we were hearing from our community was," We want more information and education about the vaccine, and we want to hear it from our healthcare providers." So from there we interviewed or we surveyed a large swath of the healthcare sector. So doctors, nurses, but also front desk people. People working in the call centers, medical assistants, LPNs. And we asked them," How do you feel about having conversations with your patients about the vaccine?" And these were all individuals working in adult healthcare. And the vast majority of them said they had never received any training on how to speak to people about vaccine hesitancy. Many of them said they weren't sure it was part of their role or that they should be having those conversations. And the vast majority said there was no workflow for what to do if they encountered someone who was vaccine hesitant. So that was a mismatch for us hearing that the whole community wanted this information from their healthcare providers. Doctors were saying," We're not even the ones in the room. We don't see the patient until they've already encountered three or four people in the doctor's office before they come to us." So there was just a huge opportunity there. So we designed a training geared towards all of the folks across the professional spectrum in healthcare settings to talk to them about, how do you have these conversations? And it really focused on a lot of what we, our community- based team, uses every day. So, motivational interviewing, therapeutic use of self, open ended questions, affirmations, building trust, and having a safe space for people to talk about their feelings towards the vaccine. So that's been a huge area of focus for us over the last several months.

Kathleen Noonan: I will just say again, because I have the contrast of working 10 years within a health system, our approach which thinks about the very first person who talks to a patient as being valuable and themselves being part of the intervention, is not typical. And one that I think does result in a different experience. Certainly the 7- Day pledge that Natasha talked about, we were able to show statistical significance in that, that involved training receptionists on how to think differently about getting a call about someone being discharged from the hospital, but also included, including that receptionist with the nurse and the doctor in the celebration when the outcomes changed. And I think healthcare needs to do more of that. I think there are many, many, many, many missed opportunities.

Paul Anderson: We hear so much in all the work we do at ECRI particularly I'll say with primary care and outpatient settings like that, we hear so much about the conflict between front of house and back of house, front office and back office. You're right. It really is a very different view of the relationship there to think of them as one unified team, rather than as, to use your earlier analogy, two teams working in parallel with each other.

Kathleen Noonan: It is. And if you have your receptionist and your medtech thinking of themselves as part of the intervention, you're halfway there.

Paul Anderson: One of the things, Natasha, I wanted to pull on, and it's a theme that we've heard in a bunch of these conversations is, you mentioned that as part of having those vaccine conversations, you had people in the community already who were already trusted within the community. How important is that versus the opposite? I guess the extreme opposite being a bunch of complete strangers parachuting from Mars." I'm going to come talk to you about the vaccine. Isn't that exciting." How important is it to have that existing relationship of trusted caregivers and just community members?

Natasha Dravid: Yeah, I think it's really important. I think we learned a lot from contact tracing and how we had people cold calling. I think there's a lot of fear, there's a lot of mistrust, there's a lot of skepticism in the community. And on the flip side, there are a lot of existing relationships, with all this incredible network of community- based organizations. We partnered with an apartment building for older citizens in Camden. We partnered with the organization that runs the needle exchange and does a lot of work with people living with HIV and with drug use. We partnered with the pediatric mobile van and all as individuals were known entities that could have these conversations. So you weren't just asking someone to take a piece of paper and say," On a scale of one to five, how likely are you..." It was more about," Talk to me, tell me. What are you thinking about the vaccine? What are some of the misinformation that you've heard that's out there in the community?" And being able to really spend 15 minutes in dialogue with someone who isn't just going to say yes, no, or not be sure who you are, where you're coming from. That I think that was critical to us getting real information, real data that we could act on. And I think with the insights that came out of it, we were able to design to it. I think some of the public messaging that we're doing is really important, getting out there boots on the ground, but also I don't think we ever would've known to target call centers for example, people in the call center who are on the phone with people calling in to say," When is the vaccine available?" It just opened up so many opportunities to leverage those relationships.

Paul Anderson: All right. So I always like to wrap up these conversations by asking for something that people who are listening can do today in their communities to start advancing safety and equity. And doing that, acknowledging they are not going to solve the whole problem today. But if they're looking to either evaluate their programs or start something from scratch, what's step one in that long list of things to do. Maybe, Natasha, if you could go first and then Kathleen, if you could follow.

Natasha Dravid: Sure. I think when thinking about programming with an eye for equity, one of the things we believe in with regard to clinical redesign is, we have data that we can use today. There's data that we can use to run retrospective analysis and get insights on claims. What are claims telling us, or what is this huge data set telling us about what's happening? But then we also have data every single day about who's coming into the healthcare system, or who's not coming into the healthcare system. I like to think about, how do we design workflows that allow providers to do something with the patient that's right in front of them or the patient that went to the emergency room yesterday that could get a call today. Working with individuals when they're in a catalytic moment of hospitalization. Working with somebody who comes through the doors of an organization. So really working towards what are real time workflows as opposed to using these big data sets that maybe are anchored a year ago or six months ago. I think that's one answer.

Kathleen Noonan: I guess the thing that I'll say is just to really see the whole team as part of the intervention. I know that what happens in health systems is you have a completely different management structure running the clinical team from the admin team. And a lot of perceived power imbalance. There's so much talk now about community health workers and the importance of community health workers. We tell people that most hospital systems right now are engined by people who could fit the community health worker definition. They're from the community, they have experience in that community. They may be in jobs that aren't the highest wage so they are struggling to make ends meet, ask them their opinion and include them. Don't just wait to have a community health worker initiative that says that that's the okay place to do that because those receptionist are gold, and the call center folks are gold. One of the things we do with the coalition is not condemn the system that exists today or the people that exists there today, but say how can we include them so that they can have a better experience, the patients can have a better experience. So I would say that would be my advice, include the person who's the admin for your department in the work.

Paul Anderson: That's great. Natasha, Kathleen, thank you both so much for being with this today.

Kathleen Noonan: Thanks very much for having us.

Paul Anderson: 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 the Camden Coalition at camdenhealth. org. 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, please visit us at ecri. org or email us at ecri- podcast @ ecri.org.