Rishi Manchanda, MD, MPH, of HealthBegins and Denard Cummings of the AMA Center for Health Equity discuss how a health system can prepare for conversations about health equity, racial equity, racism and anti-racism. They also discuss the importance of improving data quality to understand and further advance racial and health equity efforts.
Learn more in the STEPS Forward® toolkit, Racial and Health Equity: Concrete STEPS for Health Systems.
- Rishi Manchanda, MD, MPH, president and CEO, HealthBegins
- Denard Cummings, director, equitable health system integration, AMA
- Allison Winkler, senior public health consultant, HealthComms, Inc.
Winkler: We’ll go ahead and get started with today’s discussion. So, welcome to the AMA STEPS Forward® webinar series. Before we get started, we’re going to have just a couple of housekeeping items. We want to quickly review some of these so that this is an enjoyable session for all today. This session will be recorded and will be available after the event, and if you have any questions, please place them in the Q&A box located within your console. We’ll have time at the end of the webinar to answer many, if not all, of these questions. We’ll certainly do our best. And then we encourage you to reach out to us via the STEPS Forward® inbox, which is [email protected], for all questions that we’re able to address during the course of this presentation today.
Also, just want to read a quick disclaimer before we get started. The AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be legal, financial, medical or consulting advice. Thank you.
And so here’s a quick overview of today’s agenda. And we’re so pleased to be able to have our speakers today. Dr. Rishi Manchanda of HealthBegins, and Denard Cummings here with us at the AMA within our Center for Health Equity.
And just a quick introduction of these two wonderful speakers. Dr. Rishi Manchanda is the CEO of HealthBegins, which is a mission-driven consulting and technology firm that helps health care and community partners improve care and the social factors that make people sick in the first place. Client partners include the American Hospital Association, the CMS Accountable Health Communities Model, and health plans and health systems across the country.
Dr. Manchanda serves on the board of the Beyond Flexner Alliance, on the California Future Health Workforce Commission, and was a member of the HHS Health Care Payment Learning and Action Networks Primary Care Payment Model Work Group. Dr. Manchanda’s career is marked by a commitment to improving care and social determinants of health for vulnerable populations. He served as director of social medicine for a network of community health centers in South Central Los Angeles, at the South Central Los Angeles VA, and was the first chief medical officer for a self-insured employer with a large rural immigrant workforce. In his 2013 TED book, “The Upstream Doctors,” he introduced a new model of health care workers, the Upstreamists, who improve care and equity by addressing patients’ social needs like food, financial and housing insecurity. And the book has become recommended reading in medical schools and universities across the world.
I’d also like to introduce Denard Cummings. He is the director of equitable health system integration within the Center of Health Equity at the American Medical Association. He is primarily responsible for the development and implementation of the AMA push upstream strategy. By linking principles of public health into the language and practice of medicine, the strategy will better support physicians, medical students and health systems to understand all determinants of health, find ways to address structural and social determinants of health inequity, strengthen health care systems in safety, and ultimately reduce harm and inequities. Prior to his tenure at the AMA, Mr. Cummings was the inaugural director of the Bureau of Social Determinants of Health within the Office of Health Insurance Programs at the New York State Department of Health.
Within the context of a larger payment reform initiative, Denard was responsible for integrating health and human services across New York State by ensuring that the value-based payment arrangements approved by the state included a social determinants of health intervention and an executed contract with a tier one social care organization.
Mr. Cummings holds a master of public administration from the Rockefeller College of Public Affairs and Policy with a concentration in organizational management and public finance. He’s currently in the dissertation phase of a doctor of public health degree at the University of Albany School of Public Health.
And so today, Dr. Manchanda and Denard will be presenting this webinar series on Racial and Health Equity: Concrete Steps for Health Systems. And so I just want to welcome them. And it’s such a pleasure to be able to have them to join us today. And before we hand this off to Dr. Manchanda, I just want to quickly go over some of the learning objectives for today.
By the end of this webinar, our attendees will be able to identify steps to prepare your health system or large group practice for these conversations around health equity, racial equity, racism and anti-racism, describe the importance of the system-wide data, and how to improve the quality of your data to further advance racial and health equity efforts. And then explain how to advance racial and health equity in your health system using concrete steps, smart goals and quality improvement efforts. And throughout today’s discussion, these are some of the key questions that we’ll be discussing: We’ll let you know what led us to write this, what inspired us to do so, who this module is meant for, what are the concrete steps physicians can take to advance racial equity improvement efforts in your health systems or your large practice, and why this module is so important now. And so without further ado, I’ll go ahead and turn this over to Dr. Manchanda. Dr. Manchanda, welcome.
Dr. Manchanda: Allison, thank you so much. It really is first important for me to thank everybody, especially our friends at the AMA, for this opportunity and for this space, and also to extend my gratitude to everybody who’s listening in today, whether you’re joining now or listening to this recording at a later point.
The reason that I’m so grateful is because this work runs deep here at HealthBegins with our team. HealthBegins is an organization that I founded in 2012 to pursue this mission, to drive radical transformation in health equity. And in 2012, when we founded this, it was because of a longstanding understanding of what it means to actually advance health equity. And that was an understanding driven by direct experience.
For myself and many others in our network, those of us who are direct clinicians, who’ve worked at the front lines of clinical care, of public health, who understand that advancing health equity requires us to, in part, in large part, ensure that we understand how to improve the structural and social drivers of health equity. We can’t advance equity unless we advance the social and structural drivers of health equity, and that’s the mission at HealthBegins. And it’s part of the reason that we’re so privileged to share this space with you guys, but also to partner with the AMA.
And as we go to the next slide here, I’ll just explain a little bit why we wonk out so much with our friends at the AMA and many of you as we think about this. Because we know that it’s not just lip service that’s going to be sufficient to advance health equity. It’s not just thinking about these things. It’s about taking thinking and deep, rigorous, sophisticated analysis—including an understanding of systems thinking, including an understanding of the evidence—and translate that understanding into action.
And you can see here a little bit of some of the key questions on the right-hand side of the kinds of questions that we help our clients and our partners, including our friends at the AMA, to think through and then to address deeply in action. When it comes to improving health outcomes, going deeper to address the inequities that shape those outcomes, then going deeper to address the structural and social factors that shape those inequities. And then finally, as part of that process, that transformative process, shifting the mental models required to be able to do this work meaningfully. It’s for that reason that I’m privileged to join you guys today, and I can’t wait to talk more about what we’re going to present today. And then hand the baton over to my dear colleague at the AMA, Denard Cummings.
In this module, we plan to make sure that you’re able to better identify ways to prepare your health system or your large group practice for conversations about health equity using the STEPS Forward® module—as well as other resources that we can talk about—that through this conversation, that you’re better equipped to employ questions to engage other colleagues in leadership, administration, clinical care, in conversations about racial health and health equity. That you’re able to describe the importance of data, especially system-wide data to understand how to improve your racial health equity efforts.
Then finally, see how this module itself may be an additional resource for you as you think about how to advance racial health equity in your system using smart goals, using the tools of quality improvement. And so with that, it is my privilege again to yield the floor now to my friend, Denard Cummings. Denard.
Cummings: Thank you, Dr. Manchanda. And thank you, everyone, for joining us today to talk a little bit about this STEPS Forward® module, which was a very exciting opportunity to co-author with Dr. Manchanda and get this information out there. So we recognized as we were doing our work of embedding racial justice and advancing equity, that a number of health care professionals, including leaders of hospitals and large health systems, were becoming motivated to advance racial equity. These leaders needed concrete steps to translate that motivation into action inside their institution. So we decided to focus this STEPS Forward® module on how to advance racial and health equity.
The successful module offers the following five concrete steps to advance racial and health equity in your system. The first is to commit as a health system to do the work. Second is start shifting organizational norms and practices by learning about what you don’t know. Then get a handle on your data, develop a shared, clear, compelling vision and goal for the entire system, and then launch targeted improvement efforts across the system. So today, Dr. Manchanda and I are going to walk you through the five steps.
The first step is to commit as a health system to do the work. The STEPS Forward® module recommends a two-phase path for health systems to commit to organizational transformation. Phase one is to establish where you are by asking questions. Consider asking employees and colleagues questions that invite honest self-assessment within and across clinical and administrative departments. While it’s important to approach conversations about racial equity with respect and candor, expect discomfort and even some degree of conflict.
Phase two is to identify a champion. Champions should be trusted, respected voices who have a strong motivation and commitment to racial justice and health equity. As a reflection of the organization’s formal commitment to this work, champions should have an official charter and clear executive sponsorship and support.
The second step is to start shifting organizational norms and practices by learning about what you don’t know. The STEPS Forward® module recommends that organizations name it, frame it and explain it. Before making a plan to improve racial justice and health equity, it’s important for everyone in the health system to develop a better shared understanding on racism. Approach conversations with respect. Listen and be open to questions in yourself and your health system, then consider how this approach may influence culture, patient care, and consider talking with other leaders and colleagues about benefits and challenges of beginning the work, reading about experiences of other health systems advancing health equity and racial justice, partnering with internal DEI leaders, and consider hiring an experienced consultant to facilitate group conversations and normalize a commitment to racial justice and health equity.
Finally, pursue opportunities to engage and support patient community members, local leaders, especially those who belong to historically marginalized communities in the conversation.
Within the exam room, make the implicit explicit. The STEPS Forward® module offers a sample of questions that can be used to guide this process. At this point, we’re going to pass it over to Dr. Manchanda, who’s going to walk us through steps three to five.
Dr. Manchanda: Thanks, Denard. And I know we’re going through this at a quick pace here, in large part because we want to make room for questions that I know that Allison is going to help facilitate for us. And so I’ll briefly take the time and review step three in the module. I also know that we’ll probably share the link in the chat for those who are interested in actually looking at the module while you’re listening to this in real-time.
Step three, as Denard said, is about getting a handle on the data, building on some of the foundational understanding in steps one and two that have developed some of the foundational goal setting that happens. What does it mean to actually understand where there are inequities?
There are two basic questions, of course, that exist. And there’s some additional details in the module about how to answer these questions. Question one is about what does the patient data that you have currently tell you about racial inequities? In various different types of measures, measures of quality of care, measures of access to care, actual health outcomes, health-related social needs, such as food insecurity, housing stability, for example. What does that data tell you when it comes to racial inequities?
The second high-level question, of course, is what does the data from the community tell you as well? As you’ll see in the module, when we talk about these two questions, there is information about how to start to recognize some of the limitations or the challenges in answering these questions, including the fact that, in some cases, many health systems lack sufficient data on race, ethnicity, as well as primary language to be able to even discern whether there are inequities in the first place in these measures. So clearly, data collection is a major component of a strategy to be able to address this question.
And beyond that, there are additional tips and resources in the module about how to take the data that you do have and start to stratify that appropriately, to be able to identify inequities. Another element that you’ll see, part of the resources that you’ll see in the STEPS Forward® module when it comes to getting a handle on data is about how to apply a framework now to start thinking through the application of data analysis now to your available race, ethnicity, language data.
One of the resources that we share here is a commentary that was put forward by Dr. Karthik Sivashanker and Tam Duong and others at Brigham and Women’s Hospital. I should note that Dr. Sivashanker and Tam Duong are over at the AMA right now doing some wonderful work there as well, along with Denard and the rest of the team. In this framework, in this commentary that is shared in the New England Journal of Medicine Catalyst, you’ll see a framework that they propose about how to walk through methodically and assess each of these types of measures to identify if there are indeed inequities by race, ethnicity and language. Getting a handle on data, in other words, is a key step here.
The next step is, as you’re going through this process, to then develop using the insights you gain from the data itself, a shared, clear, compelling vision, as well as some clear goals that are enterprise-wide to be able to advance this work. First, this starts by having, as you can see on the left, having each department and then across departments, develop equity-focused quality improvement charters. This includes both team charters as well as project charters.
Team charters are a place, as we all know, for different stakeholders, different staff in health systems, both within and across departments, to be able to identify shared values, identify shared understanding of key terms and concepts, in this case, related to racism and racial equity, and then to be able to feed that understanding, that team itself, into action through a project charter. There are various examples here of how health systems have taken charters in the work of group activity within health systems departments to be able to mobilize activity to becoming more anti-racist. You see some examples here on the slide, and there are several other examples that are provided in more detail within the STEPS Forward® module.
These two examples here come from Brigham and Women’s and Mount Sinai Health System, who have taken substantial steps forward in thinking deeply about how they can move forward towards racial equity.
Another component of how to develop a shared compelling vision and goals is to ensure that the goals themselves are, as you all know, smart goals―Specific, Measurable, Achievable, Relevant and Time bound. A key kind of takeaway from this message and what we go into in a little bit more detail in the STEPS Forward® module is to ensure that when setting goals related to equity, that you actually do have very explicit equity goals. To put it bluntly, if equity is not a clear goal, equity will not be improved.
So for example, many of us, especially in the quality improvement space in health care systems, are traditionally used to at least setting goals for whole populations. For example, the first goal here of achieving at least a 20% increase from baseline and period of treatment rates among all adult patients, including Black men and women, using this example. Equity goals, that’s not necessarily an equity goal. It’s an overall goal for an overall population. An additional complementary goal for equity is to, in parallel, also decrease inequities in curative treatment rates between Black men and women and other groups by at least 20% from the baseline. In other words, the latter goal is a more explicit goal to decrease inequities. The more we can, and you’ll see in the STEPS Forward® module, some examples of how to develop those specific equity-focused goals.
Lastly, it’s not just about setting goals. It’s about achieving them, of course. And that happens through continuous learning, some of the steps identified, and continuous improvement. When it comes to continuous improvement, that means launching improvement efforts. Here’s where, in the STEPS Forward module, we really highlight some of the concrete examples of health system-based or health system-involved initiatives to embed racial justice and advance health equity.
You’ll see examples in the STEPS Forward® module about the ACURE trial, which is a landmark trial involving five cancer centers across the U.S. who work together to identify and then eliminate―in many cases―were successful in eliminating racial inequities and treatment and outcomes for Black patients with early-stage lung and breast cancer.
You’ll also see examples from Northwell Health, for example, the New York City Health and Hospital Systems, University of Washington Medicine, UW, and various other examples, in the STEPS Forward® module. Because as is true for all the STEPS Forward® modules, these are concrete examples that hopefully can provide some inspiration, and some templates for those in other health systems who are thinking about emulating this work.
The final step, I think the final point I’ll make about all these here is that these five steps are really meant not for all comers, for a broad kind of audience of folks who may vary in their basic understanding or their basic commitment even to racial equity. The STEPS Forward® module was, as Denard has already pointed out and as Allison mentioned, and as I will underscore, the STEPS Forward® module was designed specifically for those of you who may be listening today who are motivated already by a deeper understanding you’ve developed of what racism is, including the four forms of racism that Denard discussed in the ways that Dr. Kamara Jones and others have beautifully highlighted in the past in the literature, their understanding of racial equity, and also developed a sense of a commitment to make sure that they’re advancing equity in the work that they do every day in health systems.
The question is, if you are one of those motivated leaders, what are some of the catalytic steps that you can take to be able to move forward on this path? And so here are some of the final points here that illustrate what it’s like for motivated leaders to be able to translate that basic commitment now into some catalytic action. I will also state that as you read these points here, what Denard and I, and I think everybody else at the AMA certainly recognize is that this STEPS Forward® module is a helpful resource, but it is not the comprehensive blueprint for how to do all things racial equity.
It is impossible to take what is a long-term process of transformation and distill it down into five simple steps. These are catalytic steps meant to be helpful as part of a long-term commitment to continuous learning, continuous improvement and continuous action on the journey towards becoming an anti-racist organization and advancing racial equity. So with that, I’ll turn it over to Allison here, and maybe we can get to some good discussion.
Winkler: Great. Thank you so much, Rishi. And so we’ve got a couple of just discussion questions before we get into some of the audience questions for you and Denard, Rishi. So just looking at this from a broader perspective, for physicians and health care systems, what are you hoping most that people will take away from this module? And what change do you hope that it will spark?
Cummings: I can take a stab at this, Rishi. You can correct me where I go wrong. So this module will equip physicians and health systems with concrete steps to begin the journey of advancing racial and health equity, moving from awareness to action.
So much what Rishi just was touching on, at a minimum, I hope to see an increased awareness and the initiation of organization transformation. So an increased awareness around the different types of racism, an increased awareness around how race actually impacts the outcomes of historically marginalized populations, and then some organizational change around that.
So at least the initiation of some organizational change. I guess fully realize I would hope to see improved health outcomes for historically marginalized populations. I know that that is a little down the road, but I think that that would be a long-term goal, or visionary goal of this type of work being done within health systems. So I’ll pass it over to Rishi. Do you have any additional thoughts?
Dr. Manchanda: Well, a big plus one to that. And I’ll also say, and I think this is tracking with some of the questions that we’re seeing coming in. And really appreciate those of you who are sharing your questions. Part of the ways to increase awareness of the possibility of the fact that this is a possible path is to highlight the examples, concrete examples, of health systems already doing this work. And so some of the questions that are coming in the chat are, are there examples here of people who have applied some of these steps here?
Well, I will say two things. One is these steps are informed as much by those health systems that we scanned and tried to highlight and learned from. So these steps are not a prescriptive set of five linear steps to go through in a very concrete, methodical kind of way. It’s five steps that help to organize, hopefully, and reflect how others, health systems, are organizing this work. In other words, this is informed by practice. The other thing about this is that these steps for modules are informed by research. And in particular, the research of scholars, including scholars of color, like Dr. Kamara Jones, and others that we highlight in the references in the steps for module, this is based on the research that’s been done for years.
So there’s a lot of wisdom in both the research and the practice of what it means to actually start to translate an understanding, normative understanding of racial equity into practice. And as you’ll see in the steps for module, that increased awareness that Denard kind of talked about as our goal here is advanced by understanding some of the concrete examples of systems already doing this work. It’s not just taking our word for it. It’s knowing that these are reflections of what many in the field are starting to do and have been doing in some cases for a number of years.
So to underscore that, we give an example and a link to the work of the New York City Health and Hospital Health Systems that launched a couple years ago something called the Medical Eracism Initiative, led by their Office of Quality and Safety, and a new equity and access council that prompted the health system, again, one of the largest in the country, to discontinue the use of two race-based algorithms for the clinical assessments of kidney function and vaginal delivery after c-sections in order to help reduce racial biases in care. That’s one example.
There’s examples of how in 2016, six years ago, the University of Washington Medicine Health Care System formed a large multidisciplinary committee to advance health care equity. The following year in 2017, they released an enterprise-wide blueprint for health care equity. And then a couple of years later, that committee expanded the use of concrete performance dashboards that focused on equity. And then finally in 2020, they merged that effort over a number of years into a broader effort by creating an office of health care equity enterprise-wide to advance this work. There are examples, essentially, of many health systems that are doing this. And some of you joining today probably have your own examples, and we welcome you to share those in the Q&A as well.
Winkler: Great. Thank you, Rishi. And something that you mentioned that I think is so important in this particular topic is you talk about making it comfortable and letting people know that it’s possible. And I think that’s such an important message for so many people to hear. What would both of you say to someone that’s listening to this today that is really inspired and really wants to start these types of initiatives within their practice, but maybe they’re hesitant because this can be a very emotionally charged topic and challenging for those?
Dr. Manchanda: Yeah, I think, again, I see some similar questions in the chat. Allison, if I’m understanding your question correctly, the question is, how do you navigate these steps and the conversations that the steps imply in places where it’s laden with emotion or has been politicized or made into a partisan kind of issue?
Two things. As we said at the first kind of presentation, this module came about, it was over a year and a half, almost two years ago when we first came together to start thinking about how to produce this. And it took some time to finally get released, but it’s here now, and we’re grateful for it. And I will say something that’s been remarkable in the past two years.
As much as there has been, of course, a lot of very kind of troubling and, frankly, egregious examples of how the questions of racial equity, which are fundamentally questions about how to ensure that we’re providing the highest standard of care and ensuring the best health outcomes for patients of all racial backgrounds, of all ethnic backgrounds, regardless of which languages they speak.
The question about racial equity is that fundamentally, when it comes to health care, is fundamentally a question about how to ensure that providing the highest standard of care—whether you describe that as your triple aim, quadruple aim, quintuple aim, or you describe that as part of your professional oath—equity is about just how to be more effective as a clinician, how to provide the highest standard of care as a system, period. There are those who now are pushing back at that in different states and different parts of the country who are politicizing this in a way that, or making it a very partisan issue, and making it incredibly challenging, I think, for some to even think about how to have these conversations.
And I will say two things. That is the purpose. That is the very chilling effect that many of those who are the minority of individuals who are very vocal about their opposition to racial equity, to be quite frank, it’s exactly the intended purpose of their advocacy or their outrage right now. And sometimes they’re very egregious attacks on the reputations of people who are committed to providing the highest standard of care. What they’re trying to do is to create a chilling effect.
And this is why actually one of the initial steps, step one, as Denard kind of rightly pointed out, is about quite simply a committing. And a commitment boils down to not just an academic understanding or a professional understanding, but more deeply a question of courage. And what scholars and researchers and practitioners for the longest of time who have been working on racial equity have made clear is that this work requires courage—courage to approach this work with genuine respect, courage to facilitate and create a safe space for difficult conversations, courage to find the comfort in what are necessarily, in some cases, uncomfortable conversations about privilege, and also courage to then commit to meaningful action. It boils down in many ways, as many of you know who are already motivated to do this work, to that basic question of what it means to find courage as a leader, whether you’re a formal leader in your health system or you’re an informal leader or an emerging leader.
You should know that for the concrete examples provided in the STEPS Forward® module and many other resources that have emerged, especially in the past two years, including those produced by the American Medical Association, such as the organizational plan to embed racial justice and advance racial equity, excuse me, health equity. Many of the resources that are coming out, including this module, should give you even more reason to find that courage because you are not alone. There are many committed physicians, health system leaders, and other clinicians and caregivers in health care and in the community who know that this work is necessary and that as difficult as it may be, this work can be achieved through concrete application of some of the very steps that we try to highlight humbly in the module.
Winkler: Thank you so much, Dr. Manchanda. Sorry, Denard, were you going to add to that as well?
Cummings: I was going to add a little bit. I think that Rishi was hitting it out of the park. But I think that one of the things that’s also important to understand is in step two, we encourage individuals to develop a shared understanding. And so in many instances, these conversations are hard to have and are uncomfortable because we never talk about them. So people don’t have the full understanding of like, well, what actually is racism? Like when you say that word around me, are you accusing me of being a racist? Like what does that mean?
And so like when you begin to understand the different types of racism and you begin to understand, this is not necessarily a personal attack on any one individual, but looking at how systems function and saying, OK, well, we’re recognizing these inequitable outcomes based on the processes that are going on within these systems. I think that that kind of begins to help that process. When you have a shared and common understanding, and it should, as people know and understand better, I think that the resistance level, the hope is that the resistance level will start to subside a little. We understand, OK, what we’re trying to do is if our ultimate goal here is making sure that our patients have the best outcomes, what can I do to achieve that goal? And if it’s addressing these racial issues, then I think that everyone should be on board to do that, who’s interested in the best outcomes for their patients.
Winkler: Thank you so much. We have another wonderful question here. I think this is from Shana Koss. And she says, I applaud the internal focus on the STEPS Forward® effort. Social determinants of health (SDOH) are recognized as the larger driver of health inequity. SDOH need to be addressed upstream with multiple stakeholders across the community. But health systems may not be the entities in the best position to advance multi-stakeholder efforts. I think this is a very timely question. So what would be your advice in terms of how health systems or large practices can essentially collaborate with others to move these initiatives forward?
Cummings: I’d really defer that one to Rishi.
Dr. Manchanda: I think we’ll take this one together, because I know that you have, especially with your background in New York and other parts of the country, expertise in this area. But I’ll take a first quick pass. It’s such a great question. I also see the question in the chat from, I believe, it’s a related question from, is it Maureen? Movareen Beverly, if I’m pronouncing it correctly, related to question about social determinants.
I think there’s a two-part answer that I’ll provide to this really great question from Shana. One is building on Denard’s earlier point about getting a better understanding and shared understanding of what health equity and racial equity mean, but also what the drivers of those things are. So that’s a key step, but I want to really pause on this.
Currently, in many health systems and many parts of the health care space in general, there are really divergent and sometimes siloed conversations happening. Some people who’ve been focusing in, for example, in the community benefits departments, on social determinants of health, some within health care or population health management or care delivery teams talking about social needs, like screening for food insecurity or housing or transportation, some who are working on DEI efforts and advancing and strengthening that, especially for employees, for those we work with, including ourselves in health systems. And then even others now who are thinking about quality and safety and what does equity mean in that context. Those are just some of the various different groupings that exist right now within health care.
The challenge, I think, we see a lot is that health systems so far haven’t really developed a shared understanding of how these things are interrelated. What we say, and we’ve been doing closely with AMA and many other health systems across the country for a number of years, is to start by understanding how these things are related by putting equity at the center, health equity, defining health equity very clearly, and then identifying that it’s important to understand the social and the structural drivers of health equity.
And we really want to define that term here because social and structural drivers of health equity include, at the very basic level, four elements. Social and structural drivers include social needs, individual experience, and prioritize. So a patient, a resident in the community, may have five or six unmet social needs, like food insecurity, for example. That’s one driver, that’s one manifestation of structural determinants of health, including structural racism, but it’s also a driver of health inequity. Food insecurity, for example, among other social needs, has been clearly linked to very poor outcomes, including inequities when it comes to diabetes, heart disease, et cetera.
Beyond social needs at the individual level, there is also institutional drivers. What are the ways in which the health care system, in this case, is organized and organizes itself? What practices are in place that may present additional social barriers to health care for patients? Beyond institutional factors and individual social needs, there’s also social determinants, which are community phenomena. So not food insecurity for an individual patient, but a food desert. A food desert is a true social determinant of health, a social food insecurity is a social need. Food deserts obviously create more risk that more people living in those geographic areas where opportunities for healthy food or access to affordable housing are limited, more people are likely to experience not just unmet social needs, but also inequities.
And then finally, it’s not just about individual social needs, institutional factors and social determinants of health. It’s also why are those social determinants of health and those social needs at the community and individual level manifest in the first place? And that’s because of the structural determinants of health. And this is an area where health care itself has a relatively limited understanding but is improving rapidly in the past year.
Structural determinants include structural racism. They are, for example, manifest through supermarket redlining. The reason that there’s a food desert is because of economic choices and business choices and policy choices that have now made it such that there is no access to affordable food in those places. Food deserts don’t crop up organically. They happen because of policy choices that we as a society endorse or allow or make.
An understanding of social and social drivers in those four elements is a key part of understanding it. Now to Shannon’s question, and Movareen’s kind of question as well, that understanding translates into the second biggest action. So understanding is part one. Part two then is translating that to action. And here is where, as we say in the STEPS Forward® module, in step five, we encourage people to use what we describe at HealthBegins as a lead partner support framework.
When you identify the social and structural drivers, for example, of racial inequities when it comes to diabetes outcomes, and identify that there are various social and structural drivers contributing to those inequities. Where can the health care system lead? For example, in improving screening for patients’ social needs that are driving those inequities? Where can you partner? For example, working and showing up in those multi-stakeholder coalitions or collaboratives that are in this question here so that you can partner to be able to help address the food desert?
And then where can you support? For example, in both transforming your own institutional practices, but also lending weight, the political weight, the advocacy weight, and more importantly, the data that you have to ensure that we can address the structural drivers of the inequities in the first place, including structural drivers that address things like food insecurity, but also access to health care.
Health care systems can lead, partner and support. It is not a binary choice. It’s not either it’s something that we can do as health care systems, or we shouldn’t, because it’s somebody else’s job. It is like all things in health care. It’s a team. Just as we organize around team-based care for patients, we need to organize ourselves as part of a broader team, a broader public health approach, to be able to address the social and structural effects of health equity. I’ll pause there because obviously I care deeply about this, but I really appreciate the question. I’ll turn it over to Denard.
Cummings: No, I think you made perfectly the example that I was going to share is that from my previous role to my current role, I’ve been hearing for years how the health system is saying, well, this is not exactly what we do. This is like outside of our lane. And I will carry a message that I shared there to here. Is that we know there’s an entire public health infrastructure that’s been built around, in many instances, addressing some of these concerns. And as Rishi said, it’s just really finding, figuring out, well, where do you fit into that system? There’s an entire health care ecosystem. And how do I partner with the community organizations?
One of the things we recognize when I was in New York is that in many instances, it was hard for the health systems to get to the communities because the community simply had the health systems. They had a bad past experience with the health system. And so they needed those individuals within the community to help them navigate relationships with their patient populations and serve. So I think that the key is, as Rishi was saying, when you’re looking at these multi-stakeholder initiatives, just trying to figure out where do you fit? How can you either lead, support, or partner with these organizations to achieve the ultimate goal of, again, better health outcomes for these populations?
Winkler: Thank you so much. So we have another question here from Dr. Rohak. And so, oh, sorry. We’ve got a couple of different questions here. Sorry. Let me go back down here. So this is from Dr. Jim Rohak. It says, it appears many of the examples that we have provided in the module, they’re from both coasts. And so not from states that may support the peculiar institution resulting in a civil war that is still being fought with opposition to education in books. Are there any suggestions how to deal with external forces that resist reality of data and outcomes?
Dr. Manchanda: I can share an example. But, Denard, do you want to go first? I went first last.
Cummings: I was really processing this one about where I received it. You got me on this one.
Dr. Manchanda: Let me jump in. Let me jump in. And I also invite, I think, the audience. I’m always a fan of the kind of wisdom of everybody, especially those who are listening in. I’m sure it’s a great provocative question. And I think there’s a lot of wisdom among the attendees here.
So two things. There actually are some powerful examples. And I’ll see if there’s a way for us to share this in the chat, perhaps, with everybody. This question, maybe I’ll send it in a link to a story of, for example, a health system, Cone Health. Cone Health is in North Carolina. And we just spent some time working with them as part of a large learning collaborative that HealthBegins runs around how to address health equity and the social drivers of health equity. And one of the most powerful things is you’ll see in some of these stories, which I’ll try to put in. I might ask for some of my colleague’s help to kind of put the chat as part of the response directly to everybody here.
But one of the things that we’ve learned from Cone Health, and Cone Health, by the way, is a health system that in 1963 was mandated by a U.S. Court of Appeals to end racial segregation in terms of access to care for Black patients and also was mandated to allow Black physicians to also have privileges at the hospital as well. That case became a landmark case across the country for how to desegregate and integrate health care institutions and health systems.
Cone Health, about 50 years later, actually finally apologized to the last living plaintiff in that case, Dr. Alvin Blount. And as part of that work in the past five to 10 years, past five years in particular, what they’ve been doing since is continuing now to figure out how to make progress towards advancing racial equity, both for their patients and to do so in the community. In the stories that we’ve highlighted about what they’ve done, and there’s a beautiful video clip about three minutes long of an exchange between a health system leader and some representative, an executive director from the Greensboro Housing Coalition, a remarkable community-based organization, you see open dialogue about this history of racism and the history of institutionalized racism that exists in many parts of health care, and then a very open, courageous, candid conversation then about what it means to start to collaborate within and outside of the institution with community partners to be able to have honest, focused and action-oriented conversations around this topic.
If it’s happening in a place like Cone Health in North Carolina, which was at the center of a landmark case when it comes to racial segregation in health care, just within the past generation, if it’s happening in places like Greensboro, North Carolina, if it’s happening, and we also know it’s happening in other parts of the country, there are examples of ways in which health systems can appropriately be driven by data and driven by their mission and finally also driven by their connections with community organizations that they serve, that they work with to improve health outcomes.
It’s clear that these are the conversations that are happening. We sometimes let the vitriol and some of the toxicity that we see sometimes in the media portray a different type of set of conversations that are happening, but I will attest to the fact that just like with the Cone Health example and many other examples that we highlight in the STEPS Forward® module, there are a number of courageous leaders in health systems across the country.
I would suspect that many of you listening to this are probably one of those courageous leaders who understand that there’s a lot more movement, a lot more awareness, a lot more commitment to moving these forward, even in places where some of these conversations are becoming more and more challenging and difficult or overtly partisan. It is a set of hard conversations. The good news is a lot of these hard conversations are being had by serious thinkers and courageous leaders in health systems. There is a reality here that we sometimes don’t see manifest, at least in terms of popular media, and part of our job is to highlight these stories.
Cummings: And I think that you did a really good job with that, Rishi. The one thing that I would say is that when I’m reading the question and there is this referral to a civil war and as a referral to resistance to data, I think Rishi mentioned this in one of his earlier responses. There are examples that demonstrate that when you address equity, even if it’s like a targeted trial where you’re addressing equity for a specific subset of individuals, the impact to that has a larger impact on everyone. Everyone benefits. Like when you focus on addressing equity for historically marginalized, there’s ultimately a larger benefit to the entire population.
And I think that sometimes when you have these back-and-forth conversations, it’s really a them-versus-us. People tend to think in terms of like a zero sum, where it’s like, OK, well, if someone else gets more, I’m going to get less. And I think that I’m not going to pretend that it’s an easy conversation to have because it’s not. And especially if an individual doesn’t want to understand what you’re trying to say to them. But I think that the key is just, keep putting it out there. Keep making it obvious that nothing is being taken away from you by addressing this concern here. And ultimately, the services that are provided to everyone are going to improve because we’re focusing on providing services in this way. And so I submit to the cognitive behavioral theory. And I know sometimes it’s hard to get information in. But I’m a firm believer that when people are more informed, more exposed, that attitudes and behaviors begin to change. And resistance will begin to diminish.
Winkler: Thank you so much, Denard. And Denard and Rishi, we are receiving a lot of questions in the chat. I think for folks really looking for a concrete example of something each of you have seen in the field. For example, this was this health center that we worked with. This was the problem. This is what we did. This is the result. Because I think certainly we’re talking about this in the context of understanding definitions and how to begin and how to address. But I think some are looking for a very concrete and practical example. So if you would share one, that would be wonderful.
Dr. Manchanda: I think I’ll say just two brief things about this. One is there are a good number of examples in the STEPS Forward® module. It’s a great question. It’s actually the question that we were asking ourselves as we were trying to put together this module. You’ll see a number of examples in the module now link directly to stories of health systems that have applied some of this work.
This module and the steps outlined here are consistent with some of the emerging guides in the space and frameworks that are out there. So I would be wrong in personally illustrating that this is the only way or this is the only prescription, if you will, to follow to be able to do this work. There are a number of incredible organizations and incredible leaders across the country who develop guides. There’s work, for example, a guide called the Light and Heat Guide, a guide for health care systems produced by a number of partners, including HealthBegins and Health Leads, JSI, Johnstone Incorporated, SIREN at UCSF, and Human Impact Partners, that came together to produce a guide about a more in-depth comprehensive guide with examples of how to do this, and there are many others.
In other words, there are a lot of accompanying organizations such as those of us at HealthBegins and at the AMA, those who work with health systems across the country. And for each of those guides that are out there, there are a number of examples. So point one is there are examples in the STEPS Forward® module. And I shared one before about your health and hospital systems work and how they’ve done some of this work, or Northwell Health, Mount Sinai, Cone Health, as I just gave an example of as well. And I’ll put that link in the chat for everybody in a second. There are a number of examples.
The question, I think, the second point I’ll just make is many health systems are in different places when it comes to opportunities to move along this journey. Some are focused on, and understandably so, on how do we just get more data? And I think I see a question in the chat regarding challenges to data. Some health systems are thinking about how to improve their engagement of people with lived experience, especially those who identify with historically marginalized communities. How do you improve the engagement and center the voices of people with lived experience of racism and of other structural forms of violence?
Other health systems are thinking about now technical questions of stratification and how to do risk analytics. Other health systems are moving forward on questions of how to talk with payers to think about risk adjustment. In other words, it is not a linear kind of process, as you all know, in terms of between management and transformation in health care systems in general. And many health systems are in different places along this. I think what we’re trying to do in this support module is to be able to showcase some of the various steps that motivated leaders who are trying to increase momentum to get more involved in one or more of those kinds of important areas of equity work to kind of catalyze that work forward. And that’s what the module represents.
So we at HealthBegins, for example, just last year alone helped 67 teams from across the country representing nearly as many health systems in nine different learning collaboratives to think deeply about equity and specifically social and social drivers. That’s 67 different teams within health systems that each represent an example of how to kind of move forward along this. And I can sit here for hours just explaining each one of their journeys here. But I think the STEPS Forward® modules highlight some of them. Some of these examples here, we’re happy to follow up offline. And I know that the folks at the AMA are doing this.
Likewise, Denard, what comes to mind is the peer network, for example, that the AMA is working on, especially the thing about how to advance equity and quality and safety work that I know you and other colleagues are working on. So that’s my toss back to you as well to highlight other health systems and AMA network that are working on this.
Cummings: Thank you for saying that, Rishi. And thank you for jumping in on that. I was trying to collect my thoughts until I had a little pause there. But there are a lot of examples across the country. Like, as Rishi said, there are specific examples in the toolkit. We highlight, I think, Mount Sinai, that they’re doing some really good work with their roadmap. I know that there is some work that has been done by the Anchor Mission Network, where hospitals across the country have signed into this pledge. And so this work, there are plenty of good examples.
As Rishi said, we could probably spend all day just talking through the examples. But I encourage you, as a starting point, look at the roadmap at Mount Sinai, go to Anchor Mission Network’s website, look at some of the things they have going on there. Brigham Women’s Hospital is doing some really great work out in the Boston area.
There are many systems across the country that are doing this work and are doing really interesting and amazing things. And I think that an opportunity is to learn from them, to contact them and learn from what it is that they’re doing and how they’ve recognized success and how they’ve implemented it in a way that has been successful.
Winkler: Thank you so much. And I know we’re getting really short on time, and we have such wonderful questions. And I know we will be able to compile these post-presentation and send those out.
We do have a question. I think it’s a very important question around data collection. And data collection, as we know, this is a challenge. Do you have any recommendations from both of you on where someone should start with this? And because we’re short on time, I’ll ask you to keep your responses very brief.
Dr. Manchanda: I think in terms of data collection, there are a few different things. And you’ll see more information in the module but additional resources that we’ll be happy to share. Step one, align your racial data categories with some of the minimum standards that the federal government, including OMB, has put out. If you’re not aware of those, there’s probably ways that the AMA and through HealthBegins and others that you can learn about what those minimum standards are at the federal level so you can align with them.
Another step, provide patients with the option of self-identify their racial and ethnic identity right now to make sure that you provide more opportunities for patients to say, "Here’s how I self-identify." Make sure that you allow patients to select all that apply or choose not to respond as well, because increasingly it’s clear that as America’s demography kind of changes, as the face of America continues to kind of diversify, many people may choose several different racial categories, and that should be within their right.
Another step is to then think about how to collect more granular data, especially on ethnicity and language, along with race, in ways that reflect your local census data. Validating your data as well as a key step is where the National Quality Forum and others have provided criteria about how to validate your race, ethnicity and language data in particular. And that’s just a starting point in terms of data collection.
There are some good examples. For example, at University of California San Diego went through a wonderful process a few years ago, leveraging data in their electronic health record system to be able to identify that they had a very low number of amount of data on race, ethnicity and language. It was in the teens, in terms of percent of self-report race, ethnicity and language. They then applied a quality improvement effort and brought that up to about 90% within two years of implementing that, from low teens to 90% information. So the point is, this can be done, and there’s methodical steps that we can take to address that.
Cummings: And I’ll echo what Rishi said. It’s really about looking at the way that your system is currently collecting data, recognizing the gaps, and then implementing a process to start capturing the race, ethnicity and language data that you may not be capturing. And so many instances will recognize that we can’t stratify the data that’s being collected by these indicators, because the data is not being collected. So the first step is just to begin to look at how you’re collecting your data and then incorporate these demographic indicators into the data collection.
Winkler: Thank you so very much. And we cannot thank you enough, Dr. Manchanda and Denard, for this wonderful discussion today. And we had so many amazing questions. We will be sure to be able to compile those and be sure to get back to you with responses on that from our team at the AMA.
Additionally, we want to just introduce you to a couple of additional resources related to this. So we do have a podcast series. Dr. Manchanda interviewed for that, and that should be coming out in the coming weeks. We have our toolkit, this will really expand upon a lot of the details for the steps, additional resources, examples of some of those practices in health systems that have implemented these types of initiatives.
We have our AMA Health Equity Education Center and our AMA Center for Health Equities Guides. And this is a wonderful guide, something to definitely, as you start these types of initiatives, share with your team. There’s a wonderful glossary and a narrative of how to use language, which is very important in this particular topic.
We have additional webinar series that are going to be coming up, so please be sure to check those out.
And we just want to thank everyone that’s been on this discussion today. And again, a wonderful thank you and round of applause to Dr. Manchanda and Denard, and to all of you out there, have a wonderful day. Thank you so much.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.