What Can We Learn from Disparities in
Education to Advance the Field of
Health Disparities?
Structural Barriers, Potential Solutions, and
Lessons from the Field
Joseph R. Betancourt, M.D., M.P.H.
Director, The Disparities Solutions Center
Senior Scientist, Institute for Health Policy
Director for Multicultural Education, Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School
Quality, Disparities, and Equity
Background and Context

Quality of Health/Care Suboptimal
– Patients receive recommended services
only 54% of the time
– New focus on improving quality

Racial/Ethnic Disparities in Health/Care
– Minorities receive lower quality health care
even when controlling for SES, insurance
status, comorbidities, stage of presentation
– New focus on achieving equity
Need for Innovation
Key Challenges to Quality and Equity

Root Causes for Disparities in Health
– Social Determinants
– Access to Care

Root Causes for Disparities in Health Care
– System Factors
 Complex
to Navigate
– Provider Factors
 Communication
difficulties, stereotyping
– Patient Factors
 Mistrust,
poor understanding of condition
IOM’s Unequal Treatment
www.nap.edu
Recommendations

Increase awareness of existence of disparities

Address systems of care
– Support race/ethnicity data collection, quality improvement, evidencebased guidelines, multidisciplinary teams, community outreach
– Improve workforce diversity
– Facilitate interpretation services

Provider education
– Health Disparities, Cultural Competence, Clinical Decisionmaking

Patient education (navigation, activation)

Research
– Promising strategies, barriers to eliminating disparities
Identifying and Benchmarking Disparities:
MGH Progress to Date

Medical Policy
– Data collected, and all QI stratified by race/ethnicity




Interpreter Services
Diversity Efforts
Cross-Cultural Education for MD’s, Nurses, Staff
Unit-Based Staff Quality Rounds
– Exploring potential disparities-causing events

Patient Satisfaction
– Stratify results by r/e and added questions about respect for
culture/race/religion

Nat’l Hosp Qual Measures, HEDIS Measures
– Stratifying results by race/ethnicity

Disparities Dashboard
– Report routinely to leadership and publicly
We are including the
Core Measures for Heart
Attack, Heart Failure and
Pneumonia.
Need for Innovation
Models at Massachusetts General Hospital

Health Coaches
– Based at health care delivery site
– Assist with chronic disease management (ex. Diabetes)

Health Care Navigators
– Based at health care delivery site
– Assist with health promotion (cancer screening) and
disease prevention (cancer progression)
The MGH Chelsea Diabetes Program
Program Components
 Telephone outreach
 Individual coaching
– Address patients’ unique barriers
– Bilingual non-clinician coach, trained by DSC
– ESFT Model for coaching

Group Education
– ADA Standards
Program began in February 2006

400 Patients enrolled in coaching, 1500 coaching visits

100 Patients have gone through 4 session group education

Results: Decrease in HgbA1c close to 1.5 points
– Better than HRSA Disparities Collaborative Results recently published
Diabetes Control Improving for All:
% of Patients with Poorly Controlled Diabetes (HbA1c
> 8)
Gap between Whites and Latinos Closing
50%
40%
37%
34%
29%
30%
24%
24%
Whites
20%
20%
Latinos
10%
0%
*
2005
2006
2007
Year
* Chelsea Diabetes Management Program began in first quarter of 2006; in
2008 received Diabetes Coalition of MA Programs of Excellence Award
The MGH Chelsea Colorectal Cancer
Navigator Program
A quality improvement / disparities reduction program
initiated in Jan 2007 with 2 primary components:

Reducing systemic barriers to CRC screening
– Spanish speaking colonoscopy day; simplified test preparation
instructions in Spanish; simplified scheduling process

Implementation of a CRC Screening Navigator Program
– Bilingual, non-clinician trained in CRC screening and culturally
competent care; provides education, shared decision-making,
reminding, assisting with preparation and navigation
Results to Date:

410 patients targeted, 200 screened
Key Lessons

Allied Health Professionals Effective
– Trained from within community; cult/linguist competent
– Can expand capacity; more time with patient
– Can train in HP/DP, motivational interviewing, screening

Health Information Technology Essential
– Data collection, creation of registries; tracking, evaluation

Screening for Mental Health Critical
– 50% of patients in Diabetes program had depression

Barriers Can Be Social and Cultural
– Cultural perspectives and social circumstance

Funding and Sustainability Challenging
– Began with seed funding, then foundation funding
– Need to be creative; advocacy key