To download a PDF version of this article, click here.
Health equity is a national challenge, and healthcare executives have a responsibility to ensure their organizations are addressing disparities that disproportionately impact those historically underserved.
In a discussion with Modern Healthcare, three executives from Sutter Health, a not-for-profit healthcare system caring for 3 million patients, offer insights into their strategy to advance equitable care within their system and across the nation.
Sarah Krevans, President and CEO, Sutter Health: Our dedicated health equity team has been working for years on solutions that can be applied within our system and beyond, and we've been very intentional about addressing health equity as a measure of care quality. Sutter serves one of the most geographically and demographically diverse regions in the country – Northern California – and we also serve more of those living in poverty and traditionally underserved than any other system in our footprint. Our experience is a microcosm of the opportunities and challenges facing healthcare providers in every corner of this country, so the discoveries we make can be applied broadly.
Leon Clark, Chief Research and Health Equity Officer, Sutter Health: Yes, we don't want the Institute’s work to stop at Sutter’s doors. It’s meant to be shared and applied wherever health equity gaps exist. We are generating relevant, widely applicable, high-impact research and solutions that can be implemented directly into clinical settings. By sharing the Institute’s research, outcomes and tools with other systems, we can achieve equitable health outcomes on a national scale.
SK: Health equity was a focus for Sutter Health long before the extraordinary events of last year. But now that we're having long overdue conversations in this country about inequities in all facets of society, including healthcare, we hope more will join the effort to advance health equity.
Inequity is the most persistent challenge facing the healthcare industry today. To address it, we must change our mindset from providing equal care to equitable care, understanding that for vulnerable groups we likely need to take additional steps to achieve equitable outcomes. Equality is about what we do – the measure of the actions we take. Equity is about the result we achieve. Leaders have a responsibility to create equity by tailoring care to meet patients’ specific needs.
Kristen Azar, Scientific Medical Director, Sutter Health Institute for Advancing Health Equity: The pandemic didn't create new disparities – it exacerbated social and health inequities that have persisted for decades. Early in the pandemic, our own study found Black patients were nearly 3x more likely to be hospitalized due to COVID-19 than their non-Hispanic white counterparts. In response, we accelerated targeted, community-based interventions in impacted communities to increase access to testing and culturally competent care. And now, we're making vaccine equity a priority. The sooner more health systems measure and track care inequities – just as is done for measuring quality – the sooner effective solutions can be developed to close equity gaps.
KA: In 2018 we developed an innovative Health Equity Index (HEI) that uses real-time electronic health record (EHR) data and dynamic population health trends to uncover opportunities for addressing disparities within our system. By uncovering our own shortcomings, we made space for targeted, patient-specific improvements. The original HEI focused on ER use for conditions more effectively managed in primary and preventive care settings, like diabetes and asthma. Our HEI revealed that our Black patients in Oakland were experiencing higher than expected ER visits for asthma. With this insight, we collaborated to create a new community-based program to identify and reach these patients to help them manage their asthma and avoid the ER.
LC: Data is the engine of our health equity work and the results have been remarkable. The HEI is an important tool that has allowed us to index which populations have a greater risk of negative health outcomes and adjust for it. We've shared the tool with health systems across the country and continue to field regular requests. We're proud to help them achieve health equity for their patients.
KA: The CVEI was born out of necessity. Given our early work to identify COVID-19 disparities, Sutter leaders decided early on to make vaccine equity a priority. We used our EHR data and the healthy places index to monitor equitable vaccine uptake – taking race/ethnicity, age and socioeconomic status into account. The CVEI has helped us determine the vaccination rate necessary to overcome the virus's differential impact on each identified group. For example, because COVID disproportionately impacted Black and Hispanic patients, more of these patients need to be vaccinated to offset that impact and achieve equitable outcomes. Where equality would direct us to set the same vaccination goals across patient groups, to achieve equity we set different goals for patient subgroups that take into account the disproportionate burden of illness and hospitalization experienced by these groups.
We've been using the insights gleaned from the CVEI to set vaccine targets and measure our progress in reaching these equity goals – informing decisions about resource allocation and where to focus community outreach and efforts. This includes distributing vaccines via mobile vans and pop-up sites and reaching out to vulnerable patients by phone and text message to help them navigate the vaccination process. We’ve shared this research publicly so that other health systems and county and state agencies can use the CVEI to evaluate and tailor their own vaccination strategies.
SK: California is a bellwether state and Northern California is a microcosm of the opportunities and challenges healthcare providers face across the country. Our experience uncovering and addressing health equity can be applied almost anywhere.
Integrated health systems like Sutter are in a unique position to excel in this space. In addition to using a single, mature EHR, our system has access to selfreported and granular REAL (Race, Ethnicity, Ancestry and Language) data and robust social determinants of health data through our population health team – enabling us to produce substantive and actionable solutions and results that can be applied across our entire network. Other health systems can use our tools to do the same.
LC: This goes back to the difference between equal and equitable care. Equitable care is focused on achieving high quality outcomes for all. That’s easily said, but not easily done – which is why health equity gaps persist nationwide despite widespread agreement that they are unacceptable.
Our approach to tackling health disparities has three major components. First, start by measuring your own system's disparities to understand what’s at issue. It takes courage to do this and be transparent about your outcomes – but it’s critical to take an unvarnished look. We can’t fix a problem we don’t fully understand.
Secondly, commit to action. It's one thing to understand your performance – it’s another to change it. Kristen cited a great example of our experience with African American asthma patients. Through research we discovered that 72% of those patients were driving up to eight miles to a hospital to access care, even though they lived within one mile of a clinic. The question we faced was what to do about it – try to address this through existing channels or do something bolder? We chose the latter and partnered with a local federally qualified health center to create a community-based program that has connected at-risk patients with a respiratory therapist with outstanding results.
And, lastly, you must build your commitment into your organization’s planning and measurement to create accountability. Health equity is highly complex work that’s not going to be solved in one quarter, or one year, or even three. At Sutter, health equity is fully embedded in our quality dashboard and it is part of our long-term strategy.
KA: Maternal health is something we’ve been focused on for some time. We’re now studying how COVID-19 spreads during pregnancy – an important area of research we’re just starting to scratch the surface on. We recently completed a unique maternal study that examines differences in the exposure to COVID-19 during pregnancy among racial, ethnic and other social groups, and will be sharing our findings in the coming months. Additionally, we'll be expanding our work in maternal health equity to focus on patient experience, promotion of breast feeding and other opportunities that help us ensure access to care and optimal health outcomes for all. We're also building health equity innovation labs to improve health system equity, cancer care equity, mental health equity, cardiometabolic health equity, and equity in care transitions and access.
SK: As with any major health initiative, improving health equity is not something we can do alone. That’s why we’ve made nationwide collaboration such a central part of our initiative. We invite other health systems, hospitals and healthcare leaders to join us in our mission to make healthcare more inclusive, equitable and human for all Americans. We look forward to continued learning from our peers and working to standardize best practices across the healthcare industry.
