Racism and its Impact on Health
A guest blog from The Columbus Medical Assocation by Anita Somani, MD, OB/GYN and current Past-President of the CMA
When African-American respondents were asked about their own personal experiences regarding discrimination:
A large and growing body of research shows that the day-to-day experiences of African-Americans create physiological responses that lead to premature aging (meaning that people are biologically older than their chronological age). Or, as described in the American Behavioral Scientist, “experiences of racial discrimination are an important type of psychosocial stressor that can lead to adverse changes in health status and altered behavioral patterns that increase health risks.”
As physicians we know the statistics-Dr. Sherita Golden, chief diversity officer at Johns Hopkins describes the increased incidence of Covid-19 in people of color and the disproportionate mortality rates.
African-Americans live sicker and die sooner than whites in America. Heart disease is the number one cause of death in the United States and middle-aged black males and females have death rates that are about twice as high as their white counterparts. Elevated death rates are also evident for cancer, stroke, diabetes, kidney disease, maternal death—the list goes on. In fact, every 7 minutes, a black person dies prematurely. That’s more than 200 black people a day who would not die if the health of blacks and whites were equal.
So, what are those day to day experiences that lead to premature aging? One of the biggest ones is chronic stress. I’ve never worried about my son going for a jog or playing music too loud or going to a store or church. But when I look at this list which is a list of wrongful deaths over several years, I wonder how have we failed so many for so long?
This is a list of the people we have heard about but what about the daily injustices and slights that others experience. It wouldn’t surprise me to hear that for every name on this list there are hundreds of others who suffered the same fate without anyone knowing or experienced a near miss or whose health has suffered as a result.
As physicians we need to set the bar higher. We can start by trying to understand the stresses that people of color deal with every day. White Fragility by Robin DiAngelo discusses why it’s so hard for white people to talk about racism.
The article I have shared here gives us 65 different things we can do for racial justice. Pick one or two or even all 65 and consider doing them. Think of the change we can bring in our community if we set the bar higher and start with evaluating our own biases. The COVID pandemic is bringing the disparities in health care to the forefront and we need to evaluate and create policy that will improve these differences.
65 THINGS WHITE PEOPLE CAN DO FOR RACIAL JUSTICE
Society Groundhog Day Amidst a Prolonged Pandemic
From Columbus Medical Association Blog:
HCGC is an affiliate of CMA
Dr. Sugat Patel’s thoughts are based on what is known as of 4/17/2020.
My aim is to start a discussion on the restart of our society considering the COVID-19 pandemic will endure until there is a significant treatment or vaccine. Understanding that we may have to wait for a year or possibly more, we will have to eventually emerge, risking exposure of ourselves and loved ones to the virus. I don’t want to be long-winded, so I am going to try and present this argument by given, assumed, then proposed.
Our practices of staying at home, social distancing, and using masks have helped to flatten the curve. We are below hospital capacity and need to stay there. Our top priorities are to not exceed hospital capacity and to have enough PPE to make healthcare as safe as possible. Circumstances, where the virus is aerosolized, require maximum grade PPE. Any plan that compromises those priorities is a failure. Spread is largely through asymptomatic carriers. Many asymptomatic carriers are children. The elderly and people with comorbid conditions are extremely susceptible to morbidity and mortality.
Measures implemented are all liquid, with the goal of keeping hospitals under capacity and with appropriate supplies. The original desire for widespread testing involved the goal of finding a carrier, then isolating the carrier and contacts to prevent spread. I think once the contagion has become widespread and the asymptomatic carrier rate is significant, the value of that measure decreases. Also, the psychology of testing value may become over perceived by the public giving a false sense of security. The best way to address the contagion spread is to assume everyone is a carrier. Keeping hands clean should now be a common and frequent practice, and is the simplest preventive measure. The second most valuable measure is to block one’s own respiratory or oral secretions. To implement this measure, people should wear homemade and other masks or mouth/nose shields in public. Masks to protect oneself from inhalation of the virus, especially homemade, may be less effective, but don’t hurt and should be used as a special precaution when risks are higher (comorbid patients, broken social distancing, etc.).
Proposed (once the curve is flat and comfortable… hopefully within a month)
I am hoping most people become familiar with the practices of social distancing, frequent hand washing, and face mask or shield wearing, for these may continue for a very long time. Strict use of these practices will allow us to restart and reintegrate. A breakdown in these measures and we are back where we started. Current practices of telemedicine, teleconferencing, and tele-business should continue where practical. Most businesses should be able to restart with those constraints, along with frequent disinfecting. There will have to be enough hand washing stations and hand sanitizer for the business. These are already practiced and mandated at essential businesses. People should wear masks at work if they are not alone and 6 feet social distancing is not possible at all times. Nose and mouth shields are acceptable in low-risk environments with healthy young people.
Workplaces, where social distancing breaks down, becomes difficult. I think restaurants will have to wait a few more weeks to reopen after the lifting of the stay at home order if all goes well. When they reopen, servers and food preparers will have to wear masks. The restaurant can’t allow crowding. Bars are unique in that they depend on crowding, socializing and drinking, which make virus precautions almost impossible. They will be the last to open, which may be a long time, unfortunately. Schools are likely a hub for virus spread. I think they could restart a few weeks after the stay at home lifting. Masks or nose and mouth shields should be worn, and there should be hand sanitizer in every room. Social distancing practices should be in place. Lunchtime spacing must be created. To prevent a fail and complete pull back, high schools should start first, followed a couple weeks later by middle school, then lastly elementary school. Daycare for toddlers is a tough question. I can’t, practically, think of a way to control that environment. I would leave that to other experts, or they would have to suffer duration similar to bars and lounges.
Public transport should mandate masks or nose/ mouth shields. There should be signs to remind people to clean hands upon exit.
Gyms could also reopen as patrons could wear masks, and hand sanitizer and wipes should be aplenty. Cardio equipment should be appropriately spaced. Lap swimming at pools should be acceptable, but no “open pools” where distancing cannot be maintained.
Sports can resume if social distancing can be implemented. If not, then nose/mouth shields should be worn, by players and coaches. I can think of a simple design of a flexible over the nose fit with a firm plastic mouth shield that would leave plenty of room for breathing, but block almost all spit from talking or yelling. Hand sanitizer will, of course, need to be on the sideline. This may be difficult for wrestling to implement. Overcrowding at stadiums for spectators should not be allowed, and masks or shields should be required, along with hand sanitizer or wipes. Food and beverage should not be sold unless consumed in a private area with distancing (not at their seats).
There would have to be self-policing and social media should be helpful in whistleblowing. There will be a surge, but hopefully a very limited one. I think the under hit rural areas will especially feel a surge when the restart begins. Discipline and vigilance will be key.
What I have written here serves as my self-therapy to realize that we may be able to build a bridge to normalcy. Hopefully, it gives some hope
Sugat S. Patel, M.D.April 17, 2020
by Jack Stevens, PhD
Psychologist, Nationwide Children's Hospital
Associate Professor of Pediatrics, The Ohio State University
Dr. Stevens will be featured in HCGC's April and May Webinar Series on Behavioral Economics. Find registration information for the webinar series here.
What is behavioral economics?
Behavioral economics (BE) is an interdisciplinary field featuring concepts from psychology and economics to help people obtain their long-term goals. BE is often associated with the word “nudge,” a strategy that encourages people to make positive changes while preserving choice and freedom.
BE has often been utilized to help people make better financial decisions, such as saving more for retirement or decreasing their home energy bills. However, over the last decade, BE has been applied for health purposes in terms of assisting clinicians as well as patients.
Who are the leaders in behavioral economics across the United States?
The book Nudge was written by Richard Thaler (a University of Chicago Booth School of Business professor who won the 2017 Nobel Prize for Economics) and Cass Sunstein (a Harvard Law School and Harvard Kennedy School of Government professor).
In 2016, the University of Pennsylvania School of Medicine was the first health care system to establish its own formal behavioral economics team. BE work from this “Nudge Unit” has been featured in the New England Journal of Medicine as well as the Journal of the American Medical Association Network journals.
What are some of the success stories from behavioral economics?
BE strategies have led to positive health outcomes such as:
Why might behavioral economics appeal to clinicians, administrators, and health systems?
Past research has suggested that BE strategies often have a favorable benefit/cost ratio relative to alternative approaches. BE strategies are feasible to implement because they typically require a relatively low level of resource, such as rephrasing options for patients or altering screen displays in electronic medical record systems.
Guest Blog from The National Alliance of Healthcare Purchaser Coalitions:
Employers are the Change Agents of Healthcare
By Michael Thompson
I have often cited that employers, as the main purchasers of healthcare, sit on top of the supply chain and have the potential to lead the much-needed transformation of this market. While a number of substantive changes in this industry have come from Medicare, many improvements that have occurred in our public programs have been built on the learnings and innovations led by employers themselves. The historical list of employer-led innovation is long -- cost containment, managed care, quality measures (NCQA), hospital patient safety (The Leapfrog Group), population health, consumerism, etc.
But the job is far from done, and the issues have become even more urgent:
The time is now for a new generation of disruption and leadership from the employer community. And that is what is we are seeing as referenced by the recent article in Harvard Business Review by Walmart’s Lisa Woods, Geisinger Health System’s Dr. Jonathan Slotkin and colleagues – How Employers are Fixing Health Care and news of progress on Haven, the Amazon joint venture to revamp healthcare.
In the end, employers must act in concert, together, effecting change region by region while accelerating the ability to adapt those changes through a national framework. Our coalitions and the National Alliance can be great enablers of this next generation of employer healthcare leaders. While it’s not a new battle but the next generation of leaders is just getting started in taking it on and this change effort is essential!
Click here to visit NAHPC's website
YMCA Blood Pressure Self-Monitoring Program: TAKE ACTION FOR HEART HEALTH
by Caroline Rankin, MPH, Executive Director of Health Innovations, YMCA of Central Ohio
The YMCA of Central Ohio has been a leading force in Health and Wellness for nearly 160 years. The YMCA has been unafraid to take on life's many challenges including chronic disease, child abuse, and homelessness by offering wellness programs, child care, and housing.
Individuals come to the Y because we are a trusted community organization and can provide programming to support a healthier lifestyle. With approximately 1 in every 3 adults or 75 million American adults having been diagnosed with High Blood Pressure the YMCA provides the Blood Pressure Self-Monitoring Program. The four month program helps adults with hypertension lower and manage their blood pressure. The program focuses on regulated home self- monitoring using proper measuring techniques, individualize support and nutrition education for better blood pressure management. With the support from a trained Health Heart Ambassador a participant measures and records their blood pressure at least two times per month with a BP cuff that is provided, attend two personalized consultation per month and monthly nutritional sessions.
Research shows that the process of recording blood pressure at least twice a month over a period of four months has been shown to lower blood pressure in many people with high blood pressure.
Goals of the program include
The YMCA of Central Ohio began offering the Blood Pressure Self-Monitoring program in September 2018. The program is offered at YMCA branches, employer sites and community locations. The program is fee based and with the support of the Ohio Department of Health funding is available to support individuals at 200% or below the poverty level. In 2020 the Y will begin piloting this program with an insurer to serve a selected number of individuals with diagnosed hypertension.
A group of male residents living at the downtown Y participated in the program. The Healthy Heart Ambassador went to the Y to hold the bi-weekly check-ins and lead the monthly nutritional sessions. Joe, one of the residents shared he did not realize how serious HP pressure was and how much it impacted his health. He participated in the program to learn how to better manage his hypertension. Through the program he gained greater knowledge on his health, diet and sodium intake. He now reaches for the label and not the salt shaker. During the four months he shared his blood pressure was checked more than it had been the entire year prior. He sees taking his blood pressure as a necessity, not an inconvenience.
If you are interested in learning more on the program or how to get someone enroll please contact Caroline Rankin at firstname.lastname@example.org or visit
Update on HCGC led Patient Family Advisory Councils
by David Brackett, Vice President of Accounting and Special Projects, HCGC
In an effort to emphasize true patient-centered primary care, Comprehensive Primary Care Plus (CPC+) requires participating practices to convene Patient-Family Advisory Councils (PFACs) at each of their sites on a regular basis. Since August of 2017 HCGC has worked with Central Ohio Primary Care (COPC), the country’s largest physician owned primary care group to help facilitate PFACs at each of their 39 CPC+ sites.
Since then, COPC has held more than 375 successful council meetings engaging more than 1700 patients since. Over the last ten quarters of implementation, October-December 2018 saw the highest total attendance across all practice sites with 231 patients attending a meeting! Our average quarterly attendance total was 189 attendees and the average attendance per site at each meeting was 5 attendees. HCGC worked with staff across practices to design and execute meetings on a quarterly basis that involved patient education, experience, and quality improvement. Many practices sites were able to use PFAC members to help improve patient experience around the office and get feedback on what the practice is doing well. A representative from HCGC has been able to attend most of these meetings to gather organization wide feedback and identify themes that are prevalent across many sites. HCGC is then able to work closely with administrators at COPC to identify solutions and opportunities for additional learning and organizational growth.
Looking ahead to 2020, HCGC, COPC and their PFACs look to sustain the momentum built over the last two years to spread the information, education, and action steps taken as a result of PFAC meetings. Other questions HCGC and COPC will be asking when measuring PFAC success in 2020 and beyond are: How can practices best be supported to bolster recruitment, planning, and executing efforts? In what ways can organization administrators and practices collaborate to stimulate and drive effective, ongoing partnerships for increased quality and patient-experience. The success of PFAC meetings moving forward requires all parties working collaboratively to design, test, and implement interventions and processes that ensure the patient is at the center of their care team and the way they experience care.
How is your organization engaging patients to improve experience and quality in 2020?
If you have questions, or would like to learn more about Patient and Family Advisory Councils or engagement, please contact David Brackett at email@example.com.
Community Health Workers’ Role in Screening for Social Determinants of Health
By Tanikka C. Price, Data and Finance Director,
Central Ohio Pathways HUB
Health is more than just going to a doctor’s appointment. It is wellness; feeling good and being empowered to make decisions for yourself and your family. Health is impacted by where you live, where you work, what you eat, how you provide for your basic needs, how you get where you need to be and how safe you feel in your most intimate relationships. For too many families, health is impacted by all the things that happen before they get to the doctor’s office. These elements are known as Social Determinants of Health (SDoH).
The Central Ohio Pathways HUB (the HUB), a care coordination program managed by the Healthcare Collaborative of Greater Columbus (HCGC), deploys community health workers (CHWs) to address clients' SDoH in order to provide connections to appropriate health and social services and care to our region’s most vulnerable populations.
On December 19th, HCGC will welcome our partners at Franklin County Public Health, who will provide an update on CORE 5, a screening tool for SDoH. We know that clients in the HUB all have unique needs that need to be addressed, and learning more about CORE 5 and how it is being introduced into medical settings will be very helpful to inform the work that CHWs do for HUB clients. Click here for more information and to register for the webinar.
The Core 5 basic determinants of health are:
CHWs have the unique perspective to meet clients where they are, address their needs, as well as provide referrals to medical and social services. This has the potential to build an ongoing, trusting relationship with providers in the communities in which the HUB serves for future collaboration.
As we move into programming and education opportunities for HUB CHWs in 2020, HCGC plans to continue providing training on the various services that each HUB Care Coordination Agency (CCA) has to offer HUB clients. The ten CCAs currently participating in the HUB provide a wide array of services including pre-and post-natal care to address the infant mortality crisis, opioid prevention and treatment, theft diversion, mental health referrals and several chronic disease management and wellness services and referrals.
HUB CHWs meet clients where they are and provide access to nutritious food, housing, funding for utilities, transportation and support for those experiencing IPV. Serving as community connecters, CHWs have the unique opportunity to connect clients to services provided by CCAs, and have first-hand knowledge of what referrals are appropriate and where the most up-to-date referral sites are located. It is the relationship and trust that is built with the CHW that allows the client to follow through with the plan and referral process, which results in better outcomes and overall health for people in Central Ohio.
We hope you will join us on December 19th to learn more about the current state of the CORE 5 SDoH screening tool, and partake in a community conversation about the future of screening for SDoH.
Integrating Social Determinant of Health Data with Regional Quality Data Reporting
by Heidi Christman, Director of Communications, HCGC
Central Ohio providers continue to be open and transparent with one another about how they perform on specific quality measures with an eye on improving health and healthcare delivery across the region. HCGC is pleased to release our second regional quality report of 2019 with data on nine clinical quality measures from11 healthcare organizations representing over 140 primary care practice sites that are caring for more than 640,000 patients across Central Ohio. Our Quality Improvement Learning Group (QILG) hosts quarterly work sessions for practices and quality improvement system leaders to evaluate regional performance, set goals, and align improvement activities at a system and practice level.
Since 2014, the report has been released twice a year, providing benchmarking, trends and important insights to help as practices strive for continuous improvement. Over the years, HCGC has increased the number of practices from just over 80 reporting in 2014, to 159 in the report released earlier this year. The number of quality measures has also increased as a result of the collaborative work of the QILG.
For the first time, the most current report includes social determinant of health (SDOH) data. HCGC is excited to add this important data to our regional quality reporting, as we feel as though it will inform, expand and improve the clinical data we will continue to collect in conjunction with the traditional regional quality report. We have been able to add SDOH data because of our work with the Central Ohio Pathways HUB (the HUB.) Patient level data has been collected on both risks and outcomes that have addressed client needs in real time through the outstanding work of community health workers (CHWs) identifying, meeting with, and serving clients around central Ohio. The CHWs work at 10 care coordination agencies (CCAs), and are able to find, treat and measure client progress and SDOH data via the HUB’s information technology system. The current report focuses on HUB adult (18+ y/o males & 45+ y/o women) clients to align with the clinical data in the quality report. In this section of the report, we have highlighted hypertension data, again, as a way to align with the Controlling High Blood Pressure measure in the traditional quality report. The two sets of data are not exact comparisons in terms of reporting and collection. The HUB data is self-reported by clients, while the clinical quality transparency data is currently self-reported at the practice level. While we realize that this is just a start, and not yet actionable, we are hopeful that adding SDOH data will provide the building blocks to start gathering, analyzing and one day, acting upon this important information. In the future, we hope to add other SDOH measures that align with the clinical data, including depression/PHQ-9, breast health, pregnancy and infant mortality and diabetes/A1C.
The HUB continues to grow rapidly in terms of clients, services and agencies participating. This growth provides potential for the SDOH data to add further insight to the regional quality report as a whole regarding service delivery, trends, and gaps.
HCGC’s vision for continuing to add this data is to have a functioning integrated data system with multi-level reporting that can be contributed to and shared with providers and community partners to inform connections, performance and improvement work. It is our hope that integrating social and clinical data at a regional level will drive a cultural change in transparency and improvement, not just from a clinical and cost perspective, but also as a way to impact social and public health at a community level.
If you have questions, or would like to participate in our Quality Improvement Learning Group or the Central Ohio Pathways HUB, please contact David Brackett at firstname.lastname@example.org or Carrie Baker at email@example.com.
Emerging Opportunities to Provide Care Coordination through the Central Ohio Pathways HUB
by Heidi Christman, Director of Communications, HCGC
Since January of this year, HCGC has been managing the Central Ohio Pathways HUB, a care coordination program that links the most at-risk populations in our region to services that address their social, economic, and both mental and physical health needs. We have seen great success in connecting clients with several services including insurance enrollment; establishing a medical home with a primary care physician; access to mental health services; addiction and cessation services for drugs, alcohol and nicotine; prenatal and postnatal care for new mothers and their babies; stable, affordable housing; reliable, coordinated transportation; chronic disease management; and various education opportunities regarding a plethora of subject matter including safe sleep for babies and insurance renewal requirements. Through the supervision of ten Care Coordination Agencies (CCAs), our HUB Community Health Workers (CHWs) have enrolled 387 clients in the HUB, with 251 of those individuals being currently active in the system. Those 387 clients have accounted for over 2,800 Pathways, or connections to the aforementioned and other care and services.
At just nine months under HCGC management and just seven months of actively accepting clients, we have seen great opportunity in how we deliver these services to the community. HUBs around the country, and certainly in the state of Ohio have typically been focused on Infant Mortality and efforts to decrease racial disparities in that space. The Central Ohio Pathways HUB has certainly continued that tradition. Since March of this year, our HUB has twenty nine closed Pregnancy Pathways resulting in thirty live births (one set of twins), and twenty five of those births resulted in healthy birthweight babies, including the set of twins. Nineteen of these babies were born to black mothers, six to white mothers, and the remainder were born to mothers of various racial and ethnic backgrounds.
We are proud of this work and plan to expand and improve upon it, and we have also seen great opportunity to utilize all twenty Pathways in other sectors of the population at large. We have been thrilled to share the HUB model with our partners in the Columbus City Attorney’s Office. Since June, City Attorney Zach Klein and his team have put in place a theft diversion pilot program, which allows petty theft offenders to enter the HUB at their first court appearance. If they complete the six-month program by showing progress and a will to engage, the offense is removed from their record. There are currently HUB 26 clients enrolled in this program. City Attorney Klein and the Columbus City Council awarded Central Ohio Pathways HUB $25,000 to cover the care of clients who are not eligible for Medicaid coverage, or, as we call those instances in the HUB, in-kind clients.
Another exciting partnership that we have established just in time for Breast Cancer Awareness Month is with the Susan G. Komen of Columbus Foundation. Komen of Columbus has provided our HUB with a $15,000 grant to provide breast health education and referrals for screening and treatment to women and men who are being seen by a CHW. These grant dollars will also fund in-kind clients who are not covered by Medicaid Managed Care.
Fifty percent of breast cancer deaths in black women in Columbus are found in five zip codes. There are great racial disparities in access to quality breast health screening and referral, and Komen sees the HUB model as a great way to start to help narrow those gaps in access. CHWs in the HUB have access to unique populations, some of which are in those five area codes that are disproportionately affected by lack of access to breast health services. Through this work, CHWs will educate both women and men on self-breast health awareness, encourage clients to assess risk, identify clients at risk and link to available resources, continue addressing the other needs and social determinants of health of clients at risk, and provide feedback to Komen about barriers or issues in the system. CHWs will officially begin providing these services on October 1st, and HCGC looks forward to supporting this important work in our community.
For more information on the Central Ohio Pathways HUB, please visit our website, hcgc.org, or contact the HUB Executive Director, Jenelle Hoseus at firstname.lastname@example.org.
Columbus Medical Association Guest Blog:
Let’s “Move the Needle” on Flu Vaccination in Ohio
The Columbus Medical Association (CMA) is excited to announce that today is the launch of the “Move the Needle Challenge,” an innovative approach to increasing flu vaccinations across Ohio while providing an opportunity for physicians to receive their MOC Part IV quality improvement project credit.
CMA, in collaboration with the Healthcare Collaborative of Greater Columbus (HCGC), is a sponsor for MOC Part IV credit through the AMBS. Already, the CMA has an existing menu of approved Q/I projects and the ability to create new initiatives tailored to specific physicians. But what if all physicians in Central Ohio and beyond collectively participated on one project that would demonstrate the impact they can make in the community? Would it provide a sense of accomplishment for physicians and prove they can work together, outside of systems and specialties, for the greater good?
CMA hopes to answer these questions with the “Move the Needle Challenge.” This initiative is intended for practices, physicians, and patients to pass on to their colleagues or friends so they too can take the “challenge” and increase the number of those vaccinated for the flu this year.
The first organization to accept this challenge is Central Ohio Primary Care (COPC). “Our goal in this campaign is to increase vaccination by 20% between now and the end of the year; we challenge all clinicians in all practice settings across our community to join us," said Bill Wulf, MD, CEO Central Ohio Primary Care. "At Central Ohio Primary Care, we take flu vaccinations for ALL of our patients seriously and are so proud and excited to work with the Columbus Medical Association and our physician colleagues across the community to improve influenza vaccination rates.” said Wulf.
Each practice or participant will be able to set their own goals based on their own data and this is free for members of the CMA. "With CMA's Maintenance of Certification Part IV effort, physicians can receive needed quality improvement credits for their Medical Boards; and patients will be more protected during flu season - it's the right thing to do for our community," Wulf added. So, do what’s right for the community and take the challenge today.