Paving the Way to
Total Health:
Evaluating Health
Disparities
Howard Fullman, MD, FACG, FACP, Area Medical Director, West Los Angeles
Manuel Myers, MD, Physician in Charge, Inglewood Medical Offices
George Halverson: Key Note Presentation
National Diversity Conference 2006
Challenged Kaiser
Permanente to
evaluate and focus on
decreasing health
disparities in our
member populations
Sources: Asthma and Allergy Foundation of America
Steven Reinberg “Poorer Black Women Going Without Pap Smears, Health Day. December 27,2005
2
Institute of Medicine
Unequal Treatment: Confronting Racial and Ethnic
Disparities in Healthcare
• Racial and ethnic minorities receive lower-quality
health care than Caucasians, even when insurance
status, income, age and severity of conditions are
comparable
• The report’s first recommendation is to increase
awareness among the public, health care
providers, insurance companies and policy makers
• It also recommended the standardized collection of
data on health care access and utilization by
patients’ race, ethnicity, socioeconomic status and
where possible, primary language
Source: Institute Of Medicine. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
3
Institute of Medicine: Summary of Findings
• Racial and ethnic disparities in healthcare exist and because
they are associated with worse outcomes in many cases
(increased prevalence and severity) are unacceptable
• Racial and ethnic disparities in healthcare occur in the
context of broader historic and contemporary social and
economic inequality
• Many sources- including health systems, healthcare
providers, patients, and utilization managers- may contribute
to racial and ethnic disparities in healthcare.
• Bias, stereotyping, prejudice, and clinical uncertainty on the
part of healthcare providers may contribute to racial and
ethnic disparities in healthcare
• A small number of studies suggest that racial and ethnic
minority patients are more likely than white patients to refuse
treatment.
Source: Institute Of Medicine. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
4
Southern California Kaiser Permanente Systems
• Southern California Permanente Medical
Group Cultural Responsive Care
• Southern California Diversity Advisory
Council
• West Los Angeles (WLA) Center of
Excellence for Culturally Competent Care
5
Good Systems in Place
• Exceptional quality due to developed systems
across all races
• Proactive in prevention and quality
• Data Decision Support
• Health Connect and POINT
• Current systems need to be tested in a area with a
diverse population
Inglewood Medical Offices designated to test
our current systems and assess health
disparities in WLA Service Area
6
How Diverse Are We?
Kaiser Permanente Membership compared to America
Kaiser Permanente
Membership
United States
Population
33%
43%
57%
67%
M inority
7
White
M inority
Sources: Adult Membership, based on 2004 survey and 2005 Current Population Survey
White
How Diverse are the Inglewood Medical Offices?
Inglewood MOB Membership
1.7%
1.1%
4.9%
Caucasian
Latino
African American
Asian/Pacific Islander
Other
41.2%
51.0%
95.1% Minority
4.9% Caucasian
8
Inglewood Demonstration Project Charge and
Assumptions
• Assess the extent of racial and ethnic differences in the
Inglewood Medical Offices that are not otherwise
attributable to known factors such as access to care;
• Evaluate potential sources of racial and ethnic disparities
in healthcare, including the role of bias, discrimination, and
stereotyping at the individual (provider and patient),
institutional, and health system levels
• Promote culturally competent care, especially to those
patient groups at highest risk within particular conditions
• Provide recommendations regarding interventions to
eliminate healthcare disparities found at the Inglewood
Medical Offices
9
Background
• Inglewood’s Culturally Responsive Care
Demonstration Project committee was
created in late 2006
• To narrow the scope of their work, the group
elected to target African Americans and
Hispanics with diabetes
10
Inglewood Medical Offices
Department and Services
Primary Care Clinician Mix
• Allergy
Family Medicine
• Family Medicine and
• 10 physicians and 3 Registered Nurse
Practitioners
Internal Medicine
• Diagnostic Imaging
Internal Medicine
• Laboratory
• 8 Physicians
• Pediatrics/Teenage Medicine
• Pharmacy
• Physical Therapy
• Psychiatry
11
Study Objectives
ƒ To assess diabetic patients’ needs regarding their health
care, specifically as it relates to diabetes management.
ƒ To gather feedback from diabetic patients regarding their
care experience, for example, how they currently access
care, what barriers they experience in doing this, and how
KP can improve care delivery.
ƒ To explore whether the needs of diabetic patients vary by
ethnic group or socio-economic status; if they do, determine
what these differences are and how KP can address them.
ƒ To obtain feedback from physicians and staff regarding
barriers that prevent the delivery of culturally competent
care to diabetic patients and their recommendations for
overcoming these.
12
Phases of Inglewood Demonstration Project
• Phase 1
• Development of plan and stakeholder endorsement
• Phase 2
• Collection processes to identify patient race
• Phase 3
• Evaluation of baseline data, and identification of any Health Disparities
by population/condition
• Phase 4
• Focus groups and strategy development/selection
• Phase 5
• Strategy deployment and monitoring
• Phase 6
• Evaluation and report out
13
Baseline Data
• Limited access to racial data in
HealthConnectTM
• Physician self identified patient race from
their panels
• POINT developed a sub-database for
Inglewood patients by race to evaluate
clinical outcomes
14
Ethnicity Reported by Physicians
Inglewood Diabetes
2,992
African American
2,014
15
Hispanic
453
White / Asian / Other
102
Unknown
423
Baseline Data: Retrospective Findings
• Diabetic Patients
• Hemoglobin A1c
• LDL
• Blood pressure
16
Percent of Cohort Patients with Hemoglobin A1c
Measurement and Result in Past 12 Months
AA
HISP
100
90
80
Percentage
70
60
50
40
30
20
10
0
A1C
A1C <= 7
A1C > 9
Although Hemoglobin A1c monitoring is similar, Hispanic members are
more likely to have elevated Hemoglobin A1c > 9 than African
American members
17
Percent of Cohort Patients with LDL
Measurement and Result in Past 12 Months
AA
HISP
100
90
80
70
Percent
60
50
40
30
20
10
0
LDL
LDL <= 100
LDL > 100
Again, although LDL monitoring is similar, Hispanic members are more
likely to have elevated LDL > 100 than African American members
18
Percent of Cohort Patients with BP
Measurement and Result in 12 Months
Adjusted Odds Ratio = 1.34
P = 0.06
AA
HISP
100
90
80
70
Adjusted Odds Ratio = 0.64
P < 0.01
Percent
60
50
40
30
20
10
0
BP
BP < 130/80
BP >= 130/80
More African American members tend to have their blood pressure
monitored. Significantly less African American members have blood
pressures < 130 / 80 than Hispanic members.
19
Percent of Patients by Geography with Hemoglobin
A1c Measurement and Result in Past 12 Months
100
Adjusted Odds
Ratio = 0.64
P <0.01
WLA
Inglew ood
SCAL
90
80
Adjusted Odds
Ratio = 0.91
P < 0.04
Percentage
70
Adjusted Odds
Ratio = 0.87
P < 0.01
60
50
40
Adjusted Odds
Ratio = 1.12
P = 0.07
30
20
Adjusted Odds
Ratio = 1.33
P < 0.01
10
0
A1C
A1C <= 7
A1C > 9
Inglewood patients are significantly less likely to have Hemoglobin A1c
< 7 and more likely to have Hemoglobin A1c > 9 compared to WLA and
SCAL.
20
Percent of Patients by Geography with LDL
Measurement and Result in Past 12 Months
100
Adjusted Odds
Ratio = 0.61
P < 0.01
Adjusted Odds
Ratio = 0.89
P = 0.05
WLA
Inglew ood
SCAL
90
80
Adjusted Odds
Ratio = 1.15
P < 0.01
70
Percent
60
Adjusted Odds
Ratio = 1.16
P < 0.01
50
40
30
20
10
0
LDL
LDL <= 100
LDL > 100
Inglewood patients are significantly less likely to have LDL measurements and
more likely to have LDL > 100 compared to WLA and SCAL
21
Percent of Patients by Geography with BP
Measurement and Result in Past 12 Months
WLA
100
Adjusted Odds
Ratio = 0.82
P < 0.01
Inglew ood
SCAL
Adjusted Odds
Ratio = 0.77
P < 0.01
90
80
70
Adjusted Odds
Ratio = 0.88
P < 0.01
Percent
60
50
Adjusted Odds
Ratio = 0.78
P < 0.01
40
30
20
10
0
BP
BP < 130/80
BP >= 130/80
Inglewood patients are significantly less likely to have blood pressure
measurements and less likely to have BP < 130/80 compared to WLA and
SCAL.
22
Baseline Data
Part 1: Retrospective Conclusions
• Diabetic Patients
• Hemoglobin A1c
• Both African American and Hispanic patients have high annual Hemoglobin A1c
measurement rates (> 88%).
• Hispanic patients are more likely to have elevated Hemoglobin A1c > 9.
• Inglewood patients were significantly less likely to have Hemoglobin A1c <= 7 and
were significantly more likely to have Hemoglobin A1c >= 9 compared to WLA and
SCAL.
• LDL
• Both African American and Hispanic patients also have high annual LDL
measurement rates (> 88%).
• Hispanic patients are more likely to have an elevated LDL > 100.
• Inglewood patients were significantly less likely to have LDL measurements and
significantly more likely to have LDL > 100 compared to WLA and SCAL.
• Blood pressure
• Hispanic patients were less likely to have blood pressure measurements.
• African American patients were significantly more likely to have elevated blood
pressure >= 130 / 80.
• Inglewood patients were significantly less likely to have a blood pressure
measurement and significantly more likely to have a blood pressure >= 130 / 80.
23
Baseline Data
• Finding: Health disparities based on race
appear to be minimal at Inglewood Medical
Offices
• Hypothesis 1: Results are consistent due to
good systems across all groups
• Hypothesis 2: Performance in quality
metrics are lower in Inglewood due to
socio-economics factors
• Developed Focus Groups to investigate
further
24
Focus Groups Methodology
ƒ
To fully explore each of the study objectives, a series of focus groups were
conducted at the Inglewood MOB with the following groups:
ƒ Inglewood physicians
ƒ Inglewood staff
ƒ Higher income diabetic patients
ƒ Lower income diabetic patients
High and Low Income groups
were defined using criteria
from the Los Angeles County
section of the California
Uniform Act Income Limits
ƒ African American diabetic patients
ƒ Monolingual Spanish diabetic patients
ƒ
Organizational Research scheduled and recruited participants for all groups
ƒ
All groups were facilitated by Organizational Research with the exception of the
monolingual Spanish group
ƒ
The average length of groups ranged from approximately 90 minutes to 2 hours
25
Physicians and Staff Focus Group Findings:
Typical Care and Services to Diabetic Patients
ƒ Education (verbal and written) about diabetes
and medications
ƒ Coordination for monthly blood tests
ƒ Foot exams
ƒ Referrals to Ophthalmology for retinal screens
ƒ Referrals to Health Education for classes
ƒ Vibration sensory tests for neuropathy
ƒ Follow-up phone calls with patients
ƒ Assistance with Accu-Check machines
26
Physicians and Staff Focus Group Findings:
Perception of Members’ Barriers to Care and Managing
their Diabetes
ƒ Access to appointments due to conflicts with
work schedules
ƒ Follow up by care managers impeded due to
unreliable or incorrect phone numbers
ƒ Income related issues such as inability to afford
co-pays and prescriptions
ƒ Wait times for lab appointments
ƒ Lack of education related to diabetes at
Inglewood facility
ƒ Lack of nutrition education related to managing
their diabetes
27
Member Focus Group Findings: Barriers to
Receiving Care / Managing Diabetes
• Access to providers, laboratory, and after hours
care
• Lack of services for diabetic patients at
Inglewood (dietician, healthy eating programs,
mental health service, etc.)
• High costs
• Lack of support and education on nutrition and
secondary effects of diabetes
• Lack of support from family members in
managing diabetes
28
Member Focus Group Findings: Suggestions for
Improvements
• Group visits
• After hours visits
• Regular follow up
• Diabetic support groups
• Promote education (diet, newsletters,
classes, kp.org)
• Diabetes “hotline” or point person for
diabetes at Inglewood
29
Recommendations from Focus Groups
• Increased follow-up and support for patients with
diabetes including targeted education about diabetes,
information about medications, nutrition education,
exercise programs, etc.
• Support groups for patients with diabetes
• Improved access to providers through group
appointments, easier phone access, expanded hours,
etc.
• Improved access in the lab for blood tests by
streamlining this process for diabetic patients
• Continued emphasis on the importance of culturally
competent care and the impact this has on the patientprovider relationship and patient perceptions of care
30
Strategies Developed Based on Focus Groups
to Improve Performance
• Proactive Encounter
• Population Care Panel Management
Support
• Registered Nurse Practitioner support to
Primary Care Physicians
• Group Appointments
• Expanded hours of operation
• Targeted outreach
31
Proactive Encounter
A medical office support system for office encounters that
includes MAs, LVNs and RNs in
• Identifying interventions required by patients in support of clinical
goals (gaps) beyond those for which the encounter was intended
• Providing that information to physicians for their review and
action
• Taking action to close the gaps as directed by the physician within
their job description or scope of care
• Documenting information about the patient (medications history,
social history, smoking history, past medical history, chief
complaint, etc) to save physician time
• Interacting with patients in a helpful, courteous and respectful
manner, contributing to an outstanding patient care experience
• Assuring patient receipt of the After Visit Summary
• Increasing team work and effectiveness
32
Patient List
print out with
gaps
identified
33
Population Care Panel Management Support
• Population Management targets members that have not
had a clinical encounter for a designated period of time
and who have gaps in care for targeted clinical
conditions (such as diabetes) and gaps in preventive
care.
• Includes PCM coordinators and Team Pharmacists in
identifying the gaps, using various tools such as POINT,
providing that information to physicians, and taking
action as directed by physicians to close the gaps
without the physician having to see the patient in a face
to face visit
34
Registered Nurse Practitioner
Primary Care Physician Support
• 0.5 RNP per 5 Physicians
• Patient management by phone using POINT
system to optimize medication titration and
decrease care gaps
• RNP has no schedule
• RNP dedicated to supporting chronic care for select
physician panels
• RNP monitors lab results and titrates medications to
get patient to control more quickly working in
partnership with clinician
35
Group Appointments
Process
•
Patient list is generated for target patients (Hemoglobin A1c >8 using POINT) and given
to the nurse/back office staff (BOS) working with the PCP
•
Nurse/BOS books patients for their appointment with their physician
•
Patients are told that their co-payment for an office visit applies (Co-payment is 50% of
regular fee)
Half Day session
•
Part 1: Patient attends health education session on diabetes
•
Part 2: Physician adjusts medications individually with patients at the end of session
•
Part 3: PCM follows up with patients that have completed part 1 and part 2. Patients are
requested to go to the lab after 5 weeks to complete lab work to determine their current
Hemoglobin A1c status
•
Part 4: Patients are then booked by PCM 6 weeks post initial visit to meet with their
PCP and have their medications readjusted to Treat To Target. Group Appointment
format utilized
Goals
•
36
Treat to Target Diabetic Patients. First priority get patients that have Hemoglobin A1c>8
to target of Hemoglobin A1c<7
Group Appointments
• Patient Desired
• Focus group findings indicate members’ want
physician led groups
• Opportunity to also build Support Groups
• Efficient Utilization
• One physician for 20-30 patients
• Improved Physician satisfaction
• Advance Practitioner does follow-up and assist with
organizing sessions and charting in HealthConnectTM
• Extension of Group Appointments to four more
physicians
37
Group Appointment Results
July 2007 to November 2007
Initial Group Hemoglobin A1c Percent Change
N=28
50.0%
45.0%
40.0%
39.00%
39.00%
Improved Values
No Lab Following Initial
Encounter
35.0%
30.0%
25.0%
18.00%
20.0%
15.0%
10.0%
5.0%
4.0%
0.0%
Neutral Values
38
Poorer Values
Expanded Hours of Operation
• Departments of Laboratory and Radiology
now open Saturdays from 7am – 11:30 am
• Access is expanded to accommodate lab
testing for diabetes and mammography
• Evaluating opportunity to open both
departments earlier on weekdays
39
Targeted Outreach
• Exploring possibility to use a computerized
phone call (outreach) to members with KP
developed scripts
• Scripts have specific paths that give tips
on how to manage disease and collect
information about patient adherence to
regimens prescribed
40
Performance
Part 1: All Diabetic Members at Inglewood MOB
(Screening Rates)
A1C Screening Rates for Inglew ood Medical Offices
All Members w ith Diabetes
94.0%
92.9%
92.0%
90.6%
90.0%
88.0%
86.8%
86.1%
87.7%
87.3%
Percent
86.0%
90.4%
89.0%
90.1%
88.2%
88.2%
89.4% 89.6%
89.1%
88.7%
89.0%
90.1%
89.4%
88.9% 89.1%88.7%
83.3%
84.5%
84.0%
82.4%
91.8%
91.4%
90.8%91.0%
91.0%
92.2% 92.3%
88.5%88.2%
88.5%
88.2%
Launch Sat hours at ING for LAB start 11/1/07
83.0%
82.0%
Total Percent Change:
Inglew ood Family Med - 7.2%
Inglew ood Internal Med - 10.5%
80.0%
78.0%
Time
41
Inglewood Fam ily Med
Inglewood Internal Med
07
07
6/
20
20
/2
11
/1
2/
9/
11
/2
10
/1
5/
20
20
00
/2
10
/1
07
07
7
7
00
10
9/
17
/2
20
07
7
3/
00
9/
8/
20
/2
20
07
7
6/
8/
7/
23
/2
20
9/
00
07
7
00
7/
25
6/
6/
11
/2
/2
/2
00
00
7
7
7
28
5/
14
5/
30
/2
/2
00
00
7
7
00
4/
4/
16
/2
20
07
7
2/
00
4/
3/
19
/2
20
07
7
5/
3/
19
/2
00
07
20
2/
5/
2/
1/
22
/2
00
7
76.0%
Performance
Part 1: All Diabetic Members at Inglewood MOB
(Hemoglobin A1c >9)
A1C >9 Im provem ent for Inglew ood M edical O ffices
All M em bers w ith D iabetes
Launch APP program
35.0%
31.9%
Pharm to M D ratio is 1:15
APP to M D ratio is 1:9 (0.33 to 3)
32.2%
31.3%
30.8%30.8%
30.0%
29.6%
27.8%
25.0%
27.8%
27.8% 27.6%
26.5%
26.1%
27.9%
27.8% 27.6%
24.3%
24.1%
27.8%
27.5%
28.6% 28.2% 28.4%
28.5%
27.1% 27.4%
26.2%
25.1%
25.1%
23.4% 23.9% 23.3% 23.2%
22.8%
23.8%23.8%
22.8%22.4%
20.0%
21.7% 21.8%
20.9%20.9%
15.0%
Total Percent C hange:
Inglew ood Fam ily M ed - 5.8%
Inglew ood Internal M ed - 6.9%
APP - N /A
10.0%
5.0%
42
/3
12
9/
Int/Fam APP
/2
20
00
7
07
7
00
/1
11
/5
11
2/
/2
/2
20
00
Inglewood Internal M ed(Pharm 0.5)
10
/8
/2
/2
10
9/
24
/2
07
7
7
00
7
00
7
10
9/
27
/2
00
8/
8/
13
/2
/2
30
00
7
7
00
7
00
7/
16
/2
20
Inglewood Fam ily M ed (Pharm 0.5 )
7/
2/
00
07
7
7/
6/
18
/2
20
00
07
7
4/
6/
5/
21
/2
20
07
7
7/
5/
00
/2
23
4/
9/
20
07
7
00
/2
3/
26
/2
12
3/
4/
7
00
7
00
/2
26
2/
2/
12
/2
00
7
0.0%
Performance
Part 2: Prospective Focus on Diabetes
• Follow initial diabetes cohort of African
Americans and Hispanics over time
• Identify trends in improvement
• Monitor for successful initiatives at
Inglewood Medical Office
• Look for differences between cohort and
all diabetes patients in Inglewood, WLA
and SCAL
43
Part 2: Prospective Findings
• Diabetic Patients
• Hemoglobin A1c
• LDL
• Blood pressure
44
Percent of Patients with Hemoglobin A1c
Measurement
Inglewood
WLA
SCAL
AA
Hispanic
25
20
Percent
15
10
5
0
Nov06
Dec06
Jan-07
Feb07
Mar07
Apr-07
May- Jun-07 Jul-07 Aug-07
07
Sep07
Oct-07
Hispanic members and African American members have similar rates of
Hemoglobin A1c measurements and follow Inglewood, WLA and SCAL
45
Percent Patients with Hemoglobin A1c
Measurement and Hemoglobin A1c <= 7
Inglewood
WLA
SCAL
AA
Hispanic
Linear (Hispanic)
70
60
50
Percent
40
30
y = -1.6762x + 2197.5
R2 = 0.484
20
10
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07
Apr-07 May-07 Jun-07
Jul-07
Aug-07 Sep-07 Oct-07
Hispanic members are less likely to have a lower Hemoglobin A1c and appear
different than African American members, Inglewood, WLA and SCAL
46
Percent Patients with Hemoglobin A1c
Measurement and Hemoglobin A1c >= 9
Inglewood
WLA
SCAL
AA
Hispanic
Linear (Hispanic)
40
35
y = 1.4888x - 1894.6
R2 = 0.3788
30
Percent
25
20
15
10
5
0
Nov06
Dec06
Jan-07 Feb-07 Mar-07 Apr-07
May07
Jun-07 Jul-07 Aug-07
Sep07
Oct-07
Hispanic members are more likely to have elevated Hemoglobin A1c and
appear different than African American members, Inglewood, WLA and SCAL
47
Percent Patients with BP Measurement
Inglewood
WLA
SCAL
AA
Hispanic
50
45
40
35
Percent
30
25
20
15
10
5
0
Nov06
Dec06
Jan-07 Feb-07 Mar-07 Apr-07
May07
Jun-07 Jul-07 Aug-07
Sep07
Oct-07
African Americans are more likely to have BP measurements than
Hispanics, Inglewood, WLA and SCAL.
48
Percent of Patients with a BP Measurement
and BP > 130/80
Inglewood
WLA
SCAL
AA
Hispanic
Linear (Hispanic)
70
60
Percent
50
40
y = -1.2703x + 1681.6
2
R = 0.5933
30
20
10
0
Nov06
Dec06
Jan07
Feb07
Mar07
Apr07
May07
Jun- Jul-07 Aug07
07
Sep07
Oct07
Hispanic members are less likely to have elevated BP measurements
than African American, Inglewood, WLA and SCAL.
49
Percent of Patients with LDL Measurement
Inglewood
WLA
SCAL
AA
Hispanic
25
20
Percent
15
10
5
0
Nov06
Dec06
Jan07
Feb07
Mar07
Apr07
May07
Jun07
Jul07
Aug07
Sep07
Oct07
African American, Hispanic, Inglewood, WLA and SCAL have similar
rates of LDL measurements.
50
Percent of Cohort Patients with a LDL
Measurement and LDL > 100
Inglewood
WLA
SCAL
AA
Hispanic
70
60
Percent
50
40
30
20
10
0
Nov06
Dec06
Jan-07
Feb07
Mar07
Apr-07
May07
Jun-07 Jul-07
Aug07
Sep07
Oct-07
African American, Hispanic, Inglewood, WLA and SCAL have similar
rates of LDL > 100.
51
Part 2: Prospective Conclusions
• Diabetic Patients
• Hemoglobin A1c
• All patients (Inglewood, WLA, SCAL, AA and Hispanic) have similar monthly
rates of Hemoglobin A1c measurements.
• Hispanic patients have a decreasing trend for Hemoglobin A1c <= 7.
• Hispanic patients also have an increasing trend for Hemoglobin A1c >= 9.
• LDL
• All patients (Inglewood, WLA, SCAL, AA and Hispanic) have similar monthly
rates of LDL measurements.
• About 40% of all patients have a LDL > 100.
• Blood pressure
• African Americans patients are more likely to have BP measurements than
Hispanics, Inglewood, WLA and SCAL.
• African Americans, Hispanics and Inglewood have a recent upward trend for
BP measurements.
• Hispanic patients are less likely to have a BP > 130 / 80.
• All patients (Inglewood, WLA, SCAL, AA and Hispanic) have a downward
trend for BP > 130 / 80.
52
Summary
• Health disparities based on race are
minimal at Inglewood Medical Offices
• Performance in quality metrics when
compared to SCAL Region are lower in
Inglewood due to socio-economics factors
• Strategies to improve performance should
target patient socio demographic needs
53
Future Work - Next Steps
• Continue deployment of targeted key strategies and
monitor data in a weekly and monthly basis
• Evaluate key strategies based on outcomes and
establish continuous performance improvement
• Partner with Public Affairs/Sales and Marketing to
educate and create awareness to the Inglewood
community about their personal health
• Identify and partner with community programs in
churches, community centers, groups etc. that
provide education and resources to maintain good
health
54
QUESTIONS?