Fighting Healthcare Disparities | Outreach to those Experiencing Homelessness

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 annual Deep Dive report. This year's Deep Dive focuses on issues of racial and ethnic disparities in healthcare. We're talking to PSO members and others to hear about their initiatives to fight against these disparities. Our guest is from Pomona Valley Hospital Medical Center, an organization that strives to continuously improve the status of health. They're reaching out and serving the needs of their diverse ethnic, religious, and cultural community. Much of our guest's work focuses on providing equitable, accessible healthcare for all. To get us started, I will ask our guest to introduce himself.

Dr. Jose Ramos: Thank you so much, Paul. My name is Dr. Jose Ramos. I am a family medicine physician. I am the Associate Program Director at the Pomona Valley Hospital Sponsored Family Medicine Residency Program, so I essentially train residents.

Paul Anderson: Dr. Ramos, I think that was the brief way of describing your role. My understanding is you wear a lot of hats at the hospital and medical center there. One of the ones that we really wanted to focus on today, I think, is your role as the Director of Health Equity and Community Medicine curriculum. Could you describe a little bit of the efforts that have gone into prepare Pomona Valley to be ready to tackle some of those equity issues?

Dr. Jose Ramos: Yeah, that's a great question. I came to Pomona Valley as part of the residency program, and obviously, it's attached to the hospital with a focus on building a health equity curriculum at the program to really help develop a new generation of physicians, who are prepared to address the complex needs that we see in our diverse populations that we're serving, with really the overall goal of closing health disparities. This aligns, obviously, directly with Pomona Valley's mission. This is a sponsored program through Pomona Valley, our residency training program. It gives me opportunities to really work very, very closely with the leadership at the hospital. The curriculum that we've built translates in a lot of ways to the hospital. One of the big ways that it translates, that we're trying to implement some of the curriculum, is through the health equity, diversity, and inclusion committee, where a lot of my efforts are focused. Well, you said prepare. How do we prepare? Yeah, prepare. Great question. Prepare really is the operative word. Over the last several years, our organization as well as lots of organizations across the country have undergone a significant change as we've witnessed, horrific injustice in marginalized communities, including the murder of George Floyd. On top of that, a pandemic hits that revealed the glaring reality of health disparities that exist between communities of color and white communities. Confronting this a harsh reality forced us collectively, as a healthcare community, to acknowledge that this didn't just happen in a vacuum, didn't happen overnight, but there were pre- pandemic conditions that contributed to these health disparities that we really saw coming out of the pandemic. From a leadership standpoint at Pomona Valley, they took action, and the approach was multi- level. One was in the moment of really feeling the pain of the community, that downstream approach, addressing health disparities in real time. What we did was essentially mobilize as quickly as possible and address COVID misinformation in the community, address issues with access to COVID vaccinations, and vaccination hesitancy. We did that by partnering with community organizations to really have boots on the ground and learning from our community partners, from these experiences. This will better prepare us as we move forward, particularly when the next pandemic occurs. We have that downstream approach. Really a key piece is to also have that internal approach. By recognizing that there are structural causes of inequity, including implicit bias, we are critically looking right now at data that not only shows broadly, across the country, that we see unequal treatment of say, some of the work that we're doing is with pregnant women of color, or pain management, or chest pain, how we address that and protocols in place, particularly in communities of color. We're able to better analyze that internally and inform our decisions as we create initiatives, as we move forward. Once again, we're primarily doing this through our newly- formed inaudible committee. This committee was, once again, it was created to critically look at our institution, a way to evaluate our diversity, our inclusion, and just the help outcomes that we're seeing in our community. We look at lots of different domains, patient experience, workforce experience, and once again, we're trying to use data to really guide and inform our decisions as we move forward.

Paul Anderson: Yeah. I want to pull on that thread of data for just a second, because I think that's been a really common thread we've heard in a lot of these conversations. One of the pieces that I think relates to it is you talked about this broad initiative being something that's sponsored, that's something that's key to Pomona Valley's mission. I'm wondering how you use that data to inform and also, I guess, secure the support of the medical center's leadership at the top levels and creating, reporting back on that data in a meaningful way, but then also, as you use that data, to structure your programs and identify areas of need.

Dr. Jose Ramos: Yeah. You spoke to a key point there. You have to have leadership buy- in so that that's what it really starts with, that commitment. What kind of commitment do we have from our leadership? I think we're really fortunate to have a group, not only in our C- suite, but leaders at every single level of our institutions that are dedicated to addressing these disparities that we see in our patient populations and just creating the most inclusive workforce that we can. Now data, obviously, part of the data that we gather is collected through literature searches. Our hospital is no different than a lot of other hospitals in the area. We struggle with the exact same stuff. We see the same stigma in our emergency room when it comes to dealing with people with homelessness, with substance use disorder, possibly with mental health disorder. So we use that as a starting point. And then what we're doing is we're creating, essentially, a health equity dashboard so we can draw the data quickly from our health outcomes. We are at the beginning stages of creating this dashboard, but I think it'll really help us as we move forward.

Paul Anderson: How does that translate that? You talked about your role with residents and training residents. How does that data then translate into, and other sources as well, translate into the programs that you're developing and implementing to train staff to address health equity issues, to address implicit bias issues?

Dr. Jose Ramos: Yeah. Data is everything, and literature, honestly, is everything. When we were creating a health equity curriculum, we looked at... What we essentially did was we created a pyramid, if you will. At the base of that pyramid is a lot of data, a lot of data mining, a lot of research that supported what we were trying to teach, health equity principles, our foundational principles, essentially. We introduced the social determinants of health, supported by a lot of literature. Then we incorporate those structural components that underlie the social determinants of health, like policy and different laws, so that the residents can gain a good understanding of the interplay between what we see and how those outcomes came to be. We focus a lot on implicit bias at the residency program. We're fortunate enough to be able to protect enough time to create these really expanded workshops, focusing on how these unconscious associations we have towards certain groups of people and how that affects our patient relationships and, ultimately, care decisions. We talk about the literature that supports this, and most importantly, we talk about and we role play ways to mitigate the effects of the implicit bias. We also speak a lot about race and racism, particularly with respect to medicine. One of the things that we're looking at right now at the hospital setting is addressing some of the race- based medicine that we still see, that is based on really poor science, whether it be measuring renal function or lung capacity. But these are things that absolutely we think does not really have a place in medicine. But from physicians who have been in practice for a while, this stuff that is ingrained in us, because we learned it in our training. So that's something absolutely that that is driving us. Trainings pertaining to microaggressions and how to become a good ally with our colleagues of color, white privilege, culture of humility, and really just focusing, using that model of focusing on vulnerable populations to teach this through.

Paul Anderson: Vulnerable populations is a great segue into, I know, one of the really, I'll say, crown jewel pieces of what I know about what Pomona Valley's doing, and that's the street medicine program, the street treatment program. Can you tell me a little bit more about that program and what you do and what its goals are and how you get there?

Dr. Jose Ramos: Absolutely. Yeah. Yeah. Thank you for just opening up, giving me this opportunity to discuss it. I think that street medicine is about as downstream as you can be. These are individuals that sometimes are really maybe in the worst place they've been in their life, but there is such a tremendous need for having these types of downstream programs. And I'm really proud to work with a group of residents that identified that a couple years ago. This program is absolutely driven and run by our resident physicians, because they noticed several health gaps in our community. They essentially noticed these health gaps and asked," Is there a way that we can fill this need?" They looked at clear data that said that there was a need. The Los Angeles Homeless Services Authority, they do a one- night homeless count. It's not a perfect measure of exactly how much homelessness we're seeing in Los Angeles County, but it does still reveal alarming numbers. And this is prior to the pandemic, the last numbers we have. But it shows at least 60, 000 individuals at any period of time are experiencing homelessness, with almost 800 in the Pomona area. They looked at the sheer numbers, but they also looked at outcomes. And there, it shows that there's significant mortality of unhoused individuals. We know that chronically unhoused individuals live 12 years less than their housed counterparts. You take that 12 year less life expectancy, and if you add on, say, the burden of substance abuse, we know that people experiencing homelessness are at a 45 times greater risk of dying of overdose. So there's significant need. As part of our larger vulnerable population curriculum, we started this street medicine clinic to essentially meet the needs of our unhoused neighbors, but also to teach a process to de- stigmatize working with vulnerable populations. As you can imagine, this is a complex venture that needs a multidisciplinary approach. We can only do this with the help of our community partners. Our primary partner is Tri- City Mental Health. We were so blessed to enter into a partnership with them, because they established a trust in the community that has been built over decades. They don't do this only by providing high quality of care within the walls of their clinic. But they have street teams that go out, and they interact with their unhoused clients. These aren't doctors. These are just caring individuals who understand that continuity of care in populations experiencing homelessness may look a little bit different. It's really valuable to have organizations that have already built capacity and trust in communities, and it really makes our job much easier to reach out to the community and have that built- in trust. From an operational standpoint, we either see the patients in a pop- up clinic that we set up in different parking lots around town or via backpacking into encampments in Pomona. Essentially, the Tri- City street team, throughout the week they interact with their unhoused clients, and they create a schedule for us, They'll pick up their clients. They'll bring them to see us if they have health needs. And it's really impactful as a physician when you're able to tell your patient," Don't worry. We have people who care deeply enough about you that we'll search alleyways, encampments, wherever we think you may be, to ensure you get the care you deserve and care with dignity." This really transforms, I think, patients. You see it over time, and you see the trust for a healthcare system start to re- emerge where it may have been lost in the past. We provide lots of services. Many individuals who are experiencing homelessness have... There's some stigma associated with them, and they're a little bit worried about going to brick- and- mortar clinics or even the emergency room. With this understanding, we really take a harm- reduction approach. We try to do a lot for them on the streets. But care is a broadly- defined term, because it's not only medical care that they need. We're addressing issues that are critically important to their social needs. It's housing insecurity, food insecurity. It could be legal issues, transportation, for sure. And of course, significant morbidity from whether it be injection drug use, like soft- tissue infections, or just chronic uncontrolled diabetes, hypertension, heart failure, liver disease. Shortly after starting the street medicine clinic, it was also undeniable that our patients needed a low- barrier harm- reduction medication- assisted treatment program for individuals not only experiencing homelessness, but also suffering from opioid use disorder. Once again, the residents really took charge, and we were fortunate enough to obtain a grant through the California Academy of Family Physicians as part of a bigger collaborative with several programs in hospitals across California. We now offer Suboxone for opioid use disorder. We've also developed a curriculum specific to opioid use disorder as well as substance use disorder, just in general. We give residents protected time to ensure that they get a special waiver to be able to write these medications for use. So, it's lots of stuff that goes on with this. Obviously, there's the benefit of treating the patient in front of you, but there's lots of other benefits outside of medical treatment. Just being able to immerse resident physicians, young physicians, in this environment and providing them a framework, a philosophy, where the patient comes first, where they understand that you have to build empowered interdisciplinary teams of partners, where you're introducing practice of harm reduction principles, and just really with the underlying knowledge that housing is a primary goal, and housing really is health is how we approach our philosophy with it.

Paul Anderson: One of the things I'm privileged to do here at ECRI is work with a program that supports federally- qualified health centers and free clinics. And I know from talking to those folks over more than a decade now, when they are dealing with an unhoused population, one of the biggest challenges they face is that continuity of care. You talked about notifications, and how do I...? Do I go to the alley? Do I go to the places where I know they might be? And sending people out, and I think that really speaks volumes that you have teams of people who can do that really... It's person by person, pound the ground, so to speak, work that must be, I think, both very resource intensive in terms of people's time. But it must also be incredibly valuable in the results that it yields and keeping that continuity of care to keep people connected to the healthcare system.

Dr. Jose Ramos: Oh yeah, definitely. The teams that we work with are some of the most committed people you will ever meet. They do it because it's a moral obligation. They have a social responsibility, a social accountability to their community. It's wonderful to work with this group of people. It can absolutely be exhausting at times, but I think that's why it's so important to have these built- out teams because you're able to support each other and pick somebody up when it becomes a little bit difficult. But the outcomes of our street medicine outreach is... It's clear. We measure patient satisfaction, and we have rates nearing a hundred percent for rapport- building, for compassionate care, for increasing physician trust and increasing community bonds. We look at how well needs are addressed. In California, particularly Los Angeles County, there's a shortage, in general, of housing, affordable housing. About 30% or so do note that they have one or two needs that are not addressed, but it's most often housing. But we have teams that work tirelessly exploring county programs, state programs, national programs to try to meet those needs. We have enrolled almost 90% of our patients in Medi- Cal, our Medicaid program out here. We supply lots of different human resource services. But yeah, definitely the outcomes are really showing that this is a valuable resource to the community. I think as we move forward, what we're really going to try to measure and what we're focusing on right now is working with the hospital, particularly the emergency room department to determine exactly how much we are saving the system in general by being out on the street. My assumption is anecdotally, we look at charts and see how long we can keep certain individuals that may have been considered high utilizers in the past. Just anecdotally, we've seen incredible results. But we'd like to see more sustainable data to really support that. But we've got individuals who, every couple weeks, were showing up in the emergency room, and we've kept them out of the hospital for, say, six months at a time. It feels like we're decreasing utilization as well.

Paul Anderson: That's really remarkable. You mentioned that the work can be exhausting, and whenever I hear exhausting, I think about COVID. How has the pandemic changed the work that the street team is doing?

Dr. Jose Ramos: Yeah, another great question. Initially, right at the onset of the pandemic, nobody was prepared for the pandemic. We weren't really sure how it was affecting providers. We weren't sure how much PPE we needed. Everything was brand new. Unfortunately, for a short period of time, we actually did close it down. But we realized really quickly, within the span of just a couple weeks, that wow, we're needed more than ever right now. So we mobilized quickly. We probably weigh over- PPE'd, gowns upon gowns, gloves upon gloves, masks, everything, couldn't even breathe in them. But there was a true, true need. And I think just being out there, still providing our regular services, but also providing PPE, providing information, partnering with the Los Angeles Department of Health to ensure that there was equitable distribution vaccines. I think that was all really important to the community. I think they saw that. COVID- 19 was interesting because it was kind of a double edge sword for us, because on one hand, the uncertainty of the disease, not just our street outreach team, but a lot of our community outreach, in general, at the hospital was put on hold for some of our normal community events. However, it became really an unexpected way to engage and connect with our community. It was at a really uncertain time for them. So it showed the community how much, how invested we are in them and how committed we are to them. And this is really hospital systems at their best. In times of need, we help lift up and support our communities. It actually, I don't like using the word blessing, but in a way it was because we built new relationships, and we got to know our community at a really different, more vulnerable level.

Paul Anderson: Yeah. One of the thing you mentioned, equity in the vaccine distribution, and I'm curious if you saw that one of the things we've heard from a number of different of our folks we've spoken to has been that, okay, when there was vaccine scarcity at the very beginning, when demand was out stripping availability, well, one of the first prioritization levels was older folks, because they're very vulnerable. But then you quickly look and say," Well, folks in some of these other vulnerable populations, their life expectancy, in general, is below that age cutoff, if we're going to prioritize folks who are 75 and older, for example." I'm curious if you saw something similar and had to have those same conversations about reconsidering who were the most vulnerable, because populations of color were not going to... And I'm thinking particularly unhoused populations. You talked about a 12- year age expectancy gap, they're not going to reach that 75- year- old cutoff for that first priority level.

Dr. Jose Ramos: Yeah. We had lots of conversations. And the data though, the data was really clear, clear and, honestly, disheartening, as well. When you look at specific communities, say in Los Angeles, where you know that... Based on zip code, we know if we're talking about life expectancy, there's a dramatic difference between our more affluent, say west side of Los Angeles County, Santa Monica, the Beverly Hills area, versus what we call a southeast corridor, upwards to 15 years life expectancy difference. So it's significant. To see the resources initially really made more available to more affluent communities was disheartening. But I think that universities and community hospitals really started to take note of this quickly and tried to step up. As far as having the conversations about life expectancy, we definitely discussed it, but I think really just trying to level that playing field and trying to come to the grips and understanding exactly why we were seeing those disparities, the structural components, the historical insults that have really laid the groundwork, to see these disparities front and center during COVID, I think that's what our real focus was on

Paul Anderson: What other initiatives or programs that you're involved in with Pomona Valley would you like to highlight, particularly again, as they deal with providing equitable access to care?

Dr. Jose Ramos: Yeah. I'm really excited about the future in general. I think what we're doing, we just had our most recent community needs assessments, and now we're crunching the data, and we're reaching out to community organizations and allowing them to guide us. It's one thing to obtain some data, and then us collectively, in the hospital setting, at any committee level, to determine what we feel are the needs of the community. But it's another thing to really bring the community in and allow them to drive decision making. I'm excited that we're working now really closely with community partners to help us come up with these decisions. I will tell you this. Moving forward for the residency program this year that's upcoming, we have developed brand new gender- affirming care initiatives. That's going to be a priority for us. We have new community partners, like Pomona Pride, who we are reaching out to, getting more embedded in the LGBTQ community. We are creating stronger relationships with transitional programs. Mass incarceration is a huge issue, and so helping people reenter the system is really, really key. They've got very specific health needs. So those are two things that we're really, really excited about at moving forward, as well as thank God for our leadership. They're going to step up and get us an actual van, so we can extend ourselves a little bit, and I don't have to pack up my SUV with everything every single week. My back is hurting. They took umbrage on me. We'll also be able to be a little bit more mobile, and being more mobile, we'll be able to extend our reach and our services. I'm really excited, and I'm excited just to developing deeper partnerships with the community.

Paul Anderson: One of the things that I heard you talk about a lot, and both in existing programs and looking forward, is all the community partnerships that you've developed over the years. I always like to close by thinking about if I'm in another organization, and I don't have the kind of programs and relationships that you've developed over the years, but I want to start, because I know I have a community need, boy, what's that starting point?

Dr. Jose Ramos: Yeah. It's a great question again. Paul, these are some great questions. But yeah, we've already talked about this at the beginning, but really having commitment, champions. If your leadership buys in, I think that that really sets the direction for any institution. And commitment looks different for a lot of different organizations. But having a financial, committing finances also is going to be really important. So absolutely commitment and reflecting that level of commitment by putting resources into it. I think then too, it's do the hard work, and a lot of us, we can do this ourselves, do a lot of self- reflection before we make health equity plans and initiatives. And even reaching out into the communities, learn a little bit about the issues that are probably affecting our communities. It really needs to start by exploring these structural components of health disparities. It's hard sometimes. As physicians, as healthcare professionals, coming to grips a little bit with the fact that the most well- intentioned doctors, nurses, healthcare professionals may actually be contributing to health disparities through whether it be implicit bias or having lack of diversity in your workforce. These are hard truths to swallow. These uncomfortable conversations are important to have upfront. Lean into being, into that discomfort a little bit. The way I see it is that if your leaders of your hospital are willing to be uncomfortable, to struggle with these issues, to start that institutional cultural change, that will truly be sustainable. Definitely let data guide you as how you determine how to allocate resources, and obviously, partnering with the community. It is absolutely key. Let the community take an active role in how you approach closing disparities in your area. They may have a very, very different idea on what is truly needed in the community, no matter what data you've created.

Paul Anderson: Dr. Ramos, thank you so much for joining us today.

Dr. Jose Ramos: Thank you for having me.

Paul Anderson: You can learn more about equity and the ISMP PSO from the ECRI website at www. ecri. org, where you'll find past conversations in our podcast series, focusing on racial and ethnic disparities in care. You can find out more about Pomona Valley Hospital Medical Center at www. pvhmc. org. Be sure to subscribe to Smart Healthcare Safety on Spotify, iTunes, Google Play, or wherever you get your podcasts, get our latest episodes. We welcome your feedback. Please visit us ecri.org or email us ecri- podcasts @ ecri. org.