October 30, 2023

HOMERuN Collaborative: Incorporating and Measuring Health Equity in Inpatient Care

The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.

Organizers and Facilitators: Elizabeth (Lisa) Le, Amit Kaushal, Areeba Kara, Jennifer Readlynn, Ashley Jenkins, and Marisha Burden Background: There are many approaches to health equity in medicine. In the outpatient setting, outcomes-based dashboards have been broken down by age, gender, race with the goal of targeting improvement projects aimed at reducing inequity. In the inpatient setting, some examples of efforts to integrate health equity include routine screens for social determinants, expanded access to addiction treatment, and addressing principles of pharmaco-equity. The goal of this session was to learn more about the success and barriers people have encountered in incorporating and measuring health equity in inpatient care and ideas for improvement.

What health equity looks like in the inpatient setting

Active screening of social determinants of health (SDOH) on admission has helped to bring equity to the forefront. These screens are done by different people at different sites, including social work, physicians, and nursing. Some of these screens are embedded into admissions notes, some sites have incorporated social workers or community health workers into the inpatient team. Some sites have been able to aggressively address social determinants, with robust outpatient longitudinal case management, making sure patients have access to phones, secure transport, and in some cases housing/rental assistance. Language discordance and cultural competency are routinely identified as barriers to providing equitable care. Sites have adopted different strategies to address this including increasing resources toward in-person or video interpretation (as opposed to telephone-based interpreter services), ensuring instructions and other paperwork are provided in common languages, and intentionally hiring staff with multiple language proficiency. Efforts to mirror the patient population have been made with respect to diversity in staffing, meeting with community leaders of specific vulnerable populations, or incorporating local art reflective of the population. When possible, efforts are made for the intentional recruitment of a diverse workforce to reflect the local patient population. Barriers in transitions of care has been identified as a significant challenge impacting vulnerable populations. Many sites have created multidisciplinary transitions of care teams or clinics or identified transitions navigators to help patients access and engage in care after discharge. These teams may include hospitalists, pharmacists, social workers, and sometimes dental and PT/OT (physical therapy/occupational therapy). One site was able to show a significant cost-saving to the health care system of approximately $7 million with a transitions clinic.  The local context matters — vulnerable populations differ based on location so approaches to health equity should be tailored to the local population. For some groups, this has meant adapting equity efforts to the needs of tribal groups, refugees, and deaf populations.  Other examples of health equity work on inpatient include providing access to inpatient substance use treatment, improving access to hemodialysis though an emergency department program for those unable to easily access outpatient hemodialysis chairs, code care teams to address disruptive behavior and workplace violence without involvement of the campus police, health advocate programs, projects to address racial bias in documentation, and use of patient satisfaction data to understand the experience of underserved populations. Regarding data — few sites currently have access to data to measure health equity processes or outcomes. Examples of data to track health equity include Epic SDOH data and Vizient dashboards stratifying existing data and metrics by age, race, and other factors. One site does case-by-case tracking of mortality outcomes with an equity lens (e.g., patient primary language, was a translator used?). Another site has a DEI (diversity, equity, and inclusion) data scientist focused on pulling and analyzing data with a DEI lens. Some sites have health system leadership roles in health equity, but these are relatively new, so the impact of these roles remains to be seen.

"We try to make sure our hospital environment reflects our community, and that goes for our workforce and goes to what is on our walls, who it is created by and why it is present in these spaces."

Challenges institutions face in thinking about and incorporating health equity into inpatient care

One of the most prominent challenges has been in obtaining data to understand the current state and impact of work — some databases include race/ethnicity and others do not. Given this challenge, some sites have taken a "soft approach" to health equity — gearing work toward clearly and historically vulnerable groups with obvious needs, despite missing the data to prove the needs and focusing on access rather than outcomes. Language and cultural discordance remain a significant barrier. Despite efforts to engage in more diverse hiring, physician and advanced practice provider populations often do not mirror the general population. For example, only 5% of physicians across the country identify as Black. Lack of access to outpatient care and resources remains a significant barrier to transitioning care safely. This is largely driven by a shortage of primary care doctors and other outpatient resources. In one area, there are no community clinics in the two poorest local zip codes. Many sites lack institutional support to engage in equity work and to support equity-related resources. This can make it very challenging for hospitalists to engage in meaningful equity work without the supported time and resources to do so. In certain areas, the local political climate can make equity work geared toward specific vulnerable populations more challenging. Changes at the legislative level can make support for health equity work less certain. Despite efforts to screen SDOH, there are often still not the resources to address the SDOH. There is often a "moral distress" to providers that occurs in caring for patients with "unsolvable" problems related to their SDOH.

"It's trying to solve on-the-ground problems for people where we don't need data to know that they are not receiving equitable care and it's not about all of the outcomes we would need the data to track, but rather just trying to make sure that we are getting them the same quality care we could everybody else. But it's hard to do much more than that without a strong analytics framework."

Ideas to measure, report and address health equity in the inpatient setting

Improved access to data related to health equity remains a priority. It should be hardwired into things we are already measuring. Creation of health equity dashboards to track and measure improvement work geared toward health equity would be useful, looking at both process and outcome metrics. There is opportunity to apply an equity lens to all projects, including quality improvement projects. There need to be public policy solutions to better address and support health equity. Many of the issues our patients face are not solved by clinical solutions alone, so work to highlight issues and promote policy is critical.

"Advocacy and public policy, we can't fix these problems from the wards. We can shine light, we can't fix them."

Key Takeaways: Many sites are engaged in health equity work in the inpatient setting — with much of the current work centered on health care access, addressing social determinants of health, and improving language and cultural competency. Access to data related to health equity on inpatient remains a significant challenge, though some sites have been able to stratify existing metrics and outcomes with an equity focused lens. Ideas to support improved health equity on inpatient involve improved access to data and dashboards, and greater public policy engagement to support health equity.

We appreciate any feedback or thoughts on the findings! Please send to [email protected].

Our next meeting will be on December 8, 2023.

Image Attributions: Vector images from vecteezy.com

Check out the HOMERuN website for more information. If you would like to join the HOMERuN Collaborative calls, please reach out to [email protected].