Reaching the goal of a truly equitable health system in America will require several broad national strategies. These include a national commitment to adequate, affordable, and accessible care for all U.S. residents; greater state-level experimentation; and better designed financial assistance for coverage. It will also need a strong community health system that emphasizes social determinants of health (such as housing, transportation, and other local non-clinical factors influencing health) as well as deeper structural determinants of health inequities—including racism, the legal process, and economic barriers.
Within the context of these strategies, achieving equity also requires tactical steps that are consistent with broader strategies, building institutions and procedures within under-resourced communities that will help address the specific health needs of those neighborhoods. In our work examining health care and social determinants of health, we have encountered several examples of initiatives that should be considered as deliberate approaches to help improve health care and mitigate inequities in health—including access, resources, environment, culture, and health behaviors. Here are five examples of those approaches:
1. Telehealth to improve access to care
During the early months of the COVID-19 pandemic, telehealth became recognized as a critical tool in health care diagnosis, treatment, and triage as hospitals and clinics adapted to new conditions. By the first quarter of 2020, the Center’s for Disease Control (CDC) reported that the number of telehealth visits increased by 50 percent compared with the same time period in 2019. While there are several benefits to telehealth, including ease of access for patients with little flexibility, there are also some concerns that this shift in health care delivery could actually increase health inequality in some communities. Concerns include a widening of the digital health divide because of the challenges the technology poses for many older adults, people with limited electronic skills or low health literacy, those with limited English proficiency, and communities with poor internet connection. Indeed, a study published in early 2021 found that telemedicine use was lower in communities with higher rates of poverty.
Bringing health care services directly to a patient’s home in this way allows for a more comprehensive understanding of the conditions in which a patient resides
Fortunately, some institutions appreciate these worries and have seen telehealth not as “second best” care in poorer communities but as a potential tool to improve access and the quality of care for people who are unable or less willing to seek traditional, in-person health services. As caregivers refine this tool, and as federal investment in broadband improves access for more communities, telehealth could prove to be an important way to reduce inequities in care.
In addition, telehealth hubs and related services are proving to be valuable in improving training and quality of services in many health care institutions.
Example: Facilitated telehealth – District of Columbia
Mary’s Center is a Federally Qualified Health Center (FQHC) in the Washington, D.C.-area serving more than 60,000 patients each year.1 The majority of patients are Hispanic/Latino, a high proportion are immigrants from Central and South America, and many are undocumented and/or uninsured . The Center’s Health at Home program, or “facilitated telehealth,” has been a part of their health care delivery system since 2017. The program is conducted in partnership with local managed care organizations and helps deal with the inaccessibility and weaknesses of traditional telehealth for many—often due to structural barriers (e.g. geographic location, broadband capacity2, technical hardware, and cultural or language barriers). Facilitated telehealth essentially brings the clinic directly to the patient in their home by combining the technology with medical personnel in a home setting. Medical Assistants (MAs) are trained to go to a patient’s home and build a relationship in that “safe space.” The MA arrives with a suitcase that includes everything needed to conduct a full telemedicine visit, including a laptop, Wi-Fi hotspot, vaccines and basic medications, and equipment for blood draws and storage. The facilitated telemedicine team connects the patient and MA to a clinic-based nurse supervisor, and/or a clinic-based physician as needed.
Bringing health care services directly to a patient’s home in this way allows for a more comprehensive understanding of the conditions in which a patient resides – what they eat, their family structure, neighbor support, home safety, etc. – all of which provide an enhanced picture leading to better care. The combination of video technology and a staff person in the home also helps acclimate the patient to an often unfamiliar health system in a culturally sensitive manner. It also reduces the problem of patients who are physically unable or reluctant (e.g., because they are undocumented) to come to a clinic. As a feature of facilitated telehealth, Mary’s Center is tracking how the technique may improve outcomes, such as by establishing a much earlier connection with newly pregnant immigrant women.
Example: Project ECHO – New Mexico
At the provider level, Project ECHO uses telehealth to offer specialty consultation services to underserved communities and health care providers working in remote areas through the University of New Mexico School of Medicine. This effort began as a partnership between academic medicine, the New Mexico Department of Health, the New Mexico Corrections Department, and rural community clinics to care for individuals living in isolated environments such as prisons or rural parts of the state. Now a nationwide program, Project ECHO serves rural communities facing provider shortages and enhances a community’s access to specialty care by virtually connecting primary care physicians to specialists. During the pandemic, the program has leveraged its network of telehealth hubs to provide remote infection control training and technical assistance to nursing homes severely impacted by COVID-19. It does so through a partnership with the U.S. Department of Health and Human Services and the Agency for Health care Research and Quality (AHRQ). Funding through the CARES Act allows Project ECHO to work with approximately 9,000 nursing homes virtually; it has developed a 16-week curriculum to reduce morbidity and mortality related to COVID-19, improve infection prevention management and strategies, and provide services including virtual psycho-emotional support for staff and residents.
2. Expand health care teams
Studies have shown that team-based care is very effective in improving the coordination, efficiency, and value of care delivery for both patients and direct health providers. Creative uses of team-based care can help address limitations in available care and produce better results. International as well as U.S. cases provide models that might be replicated.
Example: The District Nurse system – United Kingdom
For over a century, the United Kingdom’s District Nurse system has used senior nurses to lead teams and work directly with patients, families, and caregivers to coordinate community-based care—including follow-up services after hospital discharges. District Nurses are team leaders who have the authority to manage the treatment of patients within their homes. They have been given the flexibility to work at the top of the licensure to treat patients and the authority to manage post-acute and chronic health care conditions. The model uses a team-based approach, with senior nurses supervising and coordinating resources among a patient’s physicians, community specialists, and other caregivers. While the model is mostly utilized for individuals with long-term health issues, the U.K. uses a similar team-based care approach for pregnant women pre- and postpartum.
The U.S. does utilize Community Health Workers (CHW) and public health nurses to improve community-based care coordination, educate patients on improving their health, and identify social determinants of health. Their role is often to supplement for shortages of health care workers and generate better understanding and trust within communities regarding health care programs. Yet these health care professionals generally lack the authority of District Nurses. Creating a U.S. version of the District Nurse model could be a powerful tool for better managing and coordinating the health of people in under-resourced communities.
Example: The CHW Cares coaching model – New York City
CHW Cares (formerly City Health Works) uses specially trained “health coaches,” hired directly from the neighborhoods they serve, to function as trusted intermediaries between the patient and health care providers. The health coaches work with patients in their homes and focus on patient involvement, disease self-management, and health education for chronic conditions (e.g., diabetes, asthma). They are trained in motivational interviewing techniques, and their main goal is to engage with patients to understand and address what is truly affecting someone’s capacity to manage their own health and so avoid unnecessary ER visits or hospitalizations. The health coaches are directly connected to the medical team by a supervisor, who can step in when an issue needs to be escalated to a medical provider while the health coach is in a patient’s home; the supervisor is connected directly to the patient’s primary care provider.
Example: Grand-Aides – International
Grand-Aides are another example of using locally-trusted individuals to build greater acceptance of medical services in the community and to extend the reach and effectiveness of health providers. Grand-Aides function as nurse extenders who have some previous training in the health field, such as medical assistants. They function almost as older members of the family being assisted. While legally Grand-Aides cannot be limited to grandparents, they are typically older individuals and bring “good grandparent” characteristics to the task of achieving successful outcomes by being a trusted and knowledgeable member of the community. They are certified nurses’ aides, with small groups of Grand-Aides supervised by a nurse. They help ensure that post-discharge patients, individuals with chronic conditions, and others follow necessary treatment steps by recording information for nurses and ensuring that patients understand and carry out nurses’ instructions. Grand-Aides are employed by health plans, clinics, hospitals, and some large employers. There are networks of Grand-Aides in dozens of U.S. communities and several other countries.
The key to the program is the close, personal relationship and trust with patients, and the seamless connection with the health system—especially important in households with less access to health promoting resources and treatment protocols. The results have been impressive, including a more than 80 percent reduction in 30-day re-admissions of patients with heart failure.
Example: The CAPABLE Program – National
The Communities Aging in Place – Advancing Better Living for Elders (CAPABLE) program is a participant-driven four-month program designed to identify an older person’s health and life goals and develop an assisted plan to achieve them. CAPABLE deploys a team consisting of an occupational therapist, a nurse, and a handyworker able to do minor household repairs and renovations. The team develops goals, addresses physical problems in the home (e.g. adding in a banister, installing a shower chair, or improving lighting), and supports a plan to enable individuals to age successfully within their own homes. This team approach of medical and non-medical providers working together to improve in-home conditions and reach each person’s goals has been shown to improve outcomes while simultaneously saving money. The Center on Medicare and Medicaid services (CMS) data shows that in-home improvements save Medicare about $20,000/person and approximately $1.9 billion annually.
By helping people to avoid health problems and accidents and supporting their life goals, the CAPABLE program is especially valuable to older individuals who do not have the resources and local services to help them age healthily. Several states are interested in adding CAPABLE to their Medicaid programs. Clearer guidance from CMS on incorporating the service into Medicaid, as well as Medicare, would help.
3. Partner with Community Assets
In an earlier report we addressed how key organizations within communities, such as religious institutions, public libraries, and even barbershops, can be effective ways to build trust and convey public health messages. These important “third places” can be powerful resources for health care delivery.
Example: Leveraging Places of Worship – National
In a report by American Muslim Health Professionals (AMHP), mosque-based health clinics were found to be pivotal in serving many underserved populations across the country. In a survey of 69 such clinics, AMHP reported that these institutions serve from as few as 50 to over 10,000 patients each year. The estimated value of services provided in these free clinics reached as much as $21 million per year in some instances, based on the number of patients seen and types of services rendered. Many of these and other clinics associated with religious institutions have been pivotal in providing COVID-19 vaccines and information dissemination as resources for the pandemic continue to become available.
The COVID-19 pandemic has laid bare vast racial and ethnic health care disparities in the U.S., and places of worship are taking some steps to address this, sometimes with government support. For instance, Choose Healthy Life, a national initiative that brings together Black clergy, was awarded a $9.9 million U.S. Department of Health and Human Services grant to establish “health navigators” within Black churches. These navigators will bring together other health care providers for immunizations and to address health issues common in Black communities, such as heart disease, hypertension, diabetes, AIDS, and asthma.
Many hospital systems now recognize that working closely with religious centers is an effective way of building trust in communities and increasing the level of care delivered. One example is The Johns Hopkins Hospital in Baltimore. Dealing with a history of deep mistrust in the Black community, as well as the need for more effective and culturally sensitive outreach in immigrant neighborhoods, several years ago Hopkins began to build stronger links with religious leaders and to hold health care information meetings in mosques and churches. The relationships of trust have helped Hopkins combat COVID-19 in many communities and improve public health.
Example: Libraries as public health hubs – National
In a previous Brookings report we explored the ways in which libraries can help build more equitable communities. Libraries are often places where people gather for warmth, shelter, internet access, and key information (e.g., job support). Recognizing this function, some library systems have trained librarians as community health specialists, expanding assistance from their traditional book lending role to providing support with employment applications, housing referrals, and health insurance enrollment. In addition, many libraries are training and equipping facilities/staff with Narcan, an opioid overdose treatment, in response to the opioid crisis. Because of the growing awareness of social, mental, and emotional needs for library patrons, some libraries are adding full-time social workers to their staff.
4. Improve coordination between housing and health care
Housing conditions and housing-based initiatives have a strong relationship with health, leading to many proposals for coordinating housing with other services and using housing as a hub for support services. An earlier Brookings report reviews ways in which housing can play a critical role in inter-sector partnerships, such as with the health system and social services. There are several examples of housing-health models that improve health equity.
Example: Data sharing in health and housing partnerships – Washington state
Health and housing partnerships that can deliver coordinated care—including needs assessments, help with the housing search, and medical referrals and supports—are often critical for improving quality of life for people with complex health conditions and/or housing instability. Better data sharing and referrals between health and housing partnerships is very important. In Washington state, the King County Housing authority works with the department of public health to share health-specific data and administrative records related to Medicaid to understand patterns linked to health care utilization amongst residents. Thanks to better information sharing, the data indicate that residents in public housing are making use of the health care system at more than double the rate of the general Medicaid population.
Example: Oklahoma City Health Centers co-located with supportive housing units
Health centers co-located in single-site supportive housing are an effective way of providing services to high-need individuals, often reducing the burden of transportation, childcare, or other competing priorities to access health care. One example is the Oklahoma City Housing Authority, which has built housing for low-income older adults alongside affordable and comprehensive health care facilities. To support such health centers, the National Association of Community Health Centers (NACHC) operates a Health Care in Public Housing Task Force, composed of 20 NACHC members who represent health centers that serve residents of public housing.
5. Increase Access to Mental Health Services
There is a serious shortage of mental health services in the United States, especially in low-income communities. This shortage means individuals are managing untreated mental health conditions, contributing to societal-level results including high levels of incarceration for poor individuals and people of color. The American Rescue Plan Act (ARPA) provides new funding for mental health initiatives, which will allow state and local governments to support some expansions of care for the most vulnerable individuals and communities. In doing so, they should review examples of initiatives that are proving effective in poorly-resourced communities.
Example: School-based clinics – Texas
The pandemic has drawn attention to the connection between school attendance and the mental health of children. In large part because of the central role of schools for families with children, school-based health centers have long proved to be an important location for linking children and their families with mental health services in an effective and culturally sensitive manner. This connection has led to greater interest in school-based mental health services. For instance, the Texas Child Mental Health Consortium provides telehealth behavioral health programs to school districts across the state. The program promises urgent appointment access to any Texas student who wants it; in 2021 the program received a 20 percent funding increase from the Texas state legislature, which means $129 million over two years for the telehealth program. Meanwhile, new ARPA funding has led to a wide range of state initiatives to support school-based mental health programs.
Example: Crisis Intervention Teams as an alternative to the police – Dallas, Texas and Olympia, Washington
We have published two previous reports on the importance and impact of shifting mental health away from police and into communities. The need for community-based mental health solutions stems from the long-standing inadequacy of mental health services in the United States. Specialized Crisis Intervention Teams (CIT) and similar approaches deal with people experiencing mental health or substance abuse crises in a manner that connects them to community resources rather than sending police officers to deal with individuals in crisis, depending on Emergency Departments for short-term care, or utilizing prisons for mental health issues.
Innovations in community-level care and the involvement of local institutions can help to reduce inequities and model approaches that will lead to improvements throughout the system.
The Rapid Integrated Group Health Team (RIGHT Care) in Dallas, Texas is an example of these new approaches. The program is a collaboration between the city’s fire-rescue department, the police department, and local hospital system. Teams consisting of a paramedic, a behavioral health clinician, and a specially trained police officer respond to 911 calls involving mental health. The result is a reduction in arrests and incarceration and an increased use of health services for people in crisis. Meanwhile, Olympia, Washington combines collaboration between police and mental health specialists with a “Familiar Faces Program,” in which local navigators with lived experience help to build trust and connections between people experiencing mental health crises and service providers to help organize longer-term treatment and supportive housing.
Major structural changes in the fabric of the U.S. health system—and in health financing—are needed to achieve true equity in health care and health conditions. Innovations in community-level care and the involvement of local institutions can help to reduce inequities and model approaches that will lead to improvements throughout the system. Policymakers need to examine such innovations and make it possible for them to expand and be replicated across communities.
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