The COVID-19 crisis and national protests against racism and police violence have laid bare our nation’s inequities in health care and society. Corey Cotton, regional ambassador for the Texas Hospital Association, says the current conversations around racial equity are not new, but the moment demands health care leaders to take “a more intentional approach” to their organization’s commitment to diversity, inclusion and equity in health care.
Texas hospitals are particularly tasked to rise to the challenge of achieving health care equity. Texas leads the nation in rates of uninsured adults with over 5 million. “I think the biggest problem we have in Texas is access to health care, especially for those who are primarily socioeconomically underserved,” says Winfred Parnell, MD, board member for Texas Healthcare Trustees and Parkland Center for Clinical Innovation, and former chair of Parkland Health and Hospital Systems’ Board of Managers in Dallas.
Texas did not elect to expand Medicaid under the Affordable Care Act, leaving about 1.5 million adults who would otherwise qualify without coverage. A 2016 study published in Preventive Medicine by researchers at the University of Alabama used data from the national Behavioral Risk Factor Surveillance program, the Centers for Disease Control and Prevention’s national survey system on health behaviors, to examine the distribution of low-income and uninsured adults in expanded versus non-expanded states, and their prevalence of chronic comorbidities. The study found that states that did not expand Medicaid under the ACA have a greater proportion of low-income, uninsured adults with more chronic disease and conditions. Black and Latino Texans are more likely to report not having a usual source of care, relying on hospital emergency departments, and difficulty in paying for health care, according to a 2018 Kaiser Family Foundation survey. The inability to access health care means a lack of preventative care to manage chronic diseases, like diabetes and hypertension - the same conditions that contribute to a greater risk of COVID-19 mortality. In Texas, age-adjusted COVID-19 deaths per 100,000 is 45.6 for Black (34%), 41.8 for Latino (31%), 26.7 for white (20%), and 19.6 for Asian individuals (15%), according to recent data from the CDC.
Cotton says Texas hospital systems can strengthen their commitment to health care equity by taking a second look at their programming for staff members. “We recreated a diversity and equity committee to re-evaluate all of our THA policies to ensure we are all on the same page and promoting diversity and inclusion,” he said.
Organizations that are diverse and inclusive reflect the society in which they exist and ensure that internal policies, social norms and behaviors support all staff members. Diverse and inclusive health care organizations are critical for promoting equitable health care, in which patient care does not vary based on a person’s gender, race/ethnicity, geographic location and socioeconomic status. Hospitals across Texas are working to address diversity and inclusion in their organizations and health equity in their patient populations.
"Hospitals can start by ensuring their leadership reflects the state’s rich diversity by expanding on initiatives that promote racial and ethnic representation in leadership positions, including C-suite and boards, and fostering a culture that is anti-racist," says Dr. Parnell.
Dr. Parnell says having anti-racist leadership greatly enhances diversity initiatives because it empowers individuals to speak forward about racism and discrimination.
“Sometimes you can be sitting at the table, but you don’t feel empowered to speak. That’s where we need real leadership to have an anti-racist approach,” said Dr. Parnell.
Diversity at the senior level is critical to providing appropriate care for patient populations in Texas, says Dr. Parnell, pointing out population projections that show the state’s racial/ethnic diversity will only increase in upcoming years. According to the Texas Demographic Center, Texas is slated to have a population of over 47 million by 2050, with over 20 million Latino (43%), six million Black (13%) and six million Asian (13%) residents compared to 13.5 million non-Hispanic white residents (29%). Much of the projected growth is based in the state’s urban areas.
Mirroring the diversity of the communities they serve, at every level of the organization, is a foundational goal for CHRISTUS Health System, headquartered in Irving, says Tiffany Capeles, FACHE, CHRISTUS’ director of health equity, diversity and inclusion, and Marcos Pesquera, vice-president for health equity, diversity and inclusion and community benefit. Pesquera said 42% of their new hires for executive positions last year were from racial/ethnic minority groups, surpassing their goal of 30%.
“We still have a long way to go, but we’ve been getting there [through] relationships with the National Association of Health Services Executives and the National Association of Latino Healthcare Executives and others,” said Pesquera. NALHE is a national organization founded in 2005 to increase senior-level Latino and Latina representation in U.S. hospitals and health systems. NAHSE is a nonprofit association of Black health care executives that was founded in 1968 to ensure the promotion and advancement of Black health care leaders. Both organizations’ goal is to elevate the quality of health care services for minority and underserved communities.
COVID-19 foregrounds the vital role social determinants play in racial health inequities. Black and Latino individuals have the highest COVID-19 diagnosis and mortality rates precisely because where they live and work increases their exposure to SARS-CoV-2. They are more likely to be public-facing essential workers but have fewer resources to isolate and otherwise protect themselves from the virus.
“We’ve always been a sick care health care system,” Dr. Parnell said, “but we’ve got to invest in the social determinants of health.”
Healthy People 2020 defines social determinants of health as conditions in the environments in which people live, learn, work, play, worship, and age; they affect a wide range of health, functioning, and quality-of-life outcomes and risks. Public health experts have long-documented how these social determinants, which includes health coverage, discrimination, and access to quality housing and food, lead to racial disparities in health. All interviewed administrators agree that pairing data on patients’ social determinants of health, with diverse, knowledgeable and committed teams can go far in achieving equitable health care.
CHRISTUS is collecting data on a patient’s social determinants through their Equity of Care Program, which started in 2018. Capeles said the program aligns with the American Hospital Association’s Equity of Care Pledge to fulfill the intent of meaningful use practices, by stratifying utilization data by race, ethnicity, language, gender, age, payor mix, zip code and more to identify areas of focus to better care for our vulnerable communities.
Their team identified the primary diagnosis of hypertension as the first area of focus: “Individuals were coming to our emergency department just to address their hypertension.”
CHRISTUS Care Managers contacted those identified patients to measure the social determinants that impacted their health. Capeles said they focused on four areas that would make the most impact:
- access to a primary care physician;
- medical transportation;
- prescription assistance; and
- health education.
When the pandemic settled into Texas, CHRISTUS adjusted the program to focus on their COVID-19 patient population, ensuring low-income patients had access to medication, food and other health care resources needed to isolate and recover from the disease. The program has served over 750 patients so far in their San Antonio hospitals.
Capeles said partnering with community organizations has been crucial to coordinating resources, like grocery shopping and delivery for patients, so infected patients can stay home and prevent further community spread. CHRISTUS links patients with the Health Collaborative in San Antonio and the San Antonio Food Bank, which prepares and distributes food packages to residents in need.
Currently, CHRISTUS is piloting a program to remotely monitor patients who are COVID-19 positive or presenting symptoms. Patients stay home, are provided with supplies, such as a thermometer and a pulse oximeter, to enter their biodata through a smartphone application, while being monitored by a provider at a facility. Capeles says the service is available regardless of payor type and, so far, patients are “comforted in knowing someone is monitoring them.” She adds the program helped with the COVID-19 surge by allowing hospitals to have more capacity to meet the needs of more seriously ill patients.
Building a culture of diversity, inclusion and anti-racism for health systems’ staff is critical to building out programs and resources that support health equity for patient populations. CHRISTUS has employed the GLINT survey to measure staff’s sense of inclusion and belonging and to identify managers “for training on how to grow, improve and model inclusive behaviors,” said Pesquera. The four-hour training tool includes lectures, practicums and case studies for managers to model more inclusive behaviors.
Recognizing that not everyone has the tools to have much-needed conversations around race, bias, and health care inequities, leading to anxiety and avoidance, Pesquera says they provide training for leadership staff on how to engage in “brave conversations about race.”
“We think it’s important to have these conversations and it’s not on Black employees to start them. It’s on all of us to have them,” he said. The first training brought in over 120 self-selected leaders, primarily white, who wanted to have “these conversations within their ministries.” Since then, an additional 113 staffers have completed the online training.
In addition, CHRISTUS has held unconscious bias training for those in leadership positions - over 2,400 executives, directors and managers. Pesquera says the goal of the program is for staff to share a “common language when referring to unconscious bias,” practice active awareness of bias in the workplace, and model inclusive behaviors. “While we recognize that these are uncomfortable conversations, our goal is to establish a way to talk about those things openly.”
Capeles adds that they also provide training for clinicians on cultural competency and are in the process of developing one for their physician residency program.
The current moment presents exciting opportunities to restructure health care systems for the better and build on the spirit of collaboration in the fight against COVID-19. Cotton points to THA’s Personal Protective Equipment Sharing Network, a collaborative effort between member hospitals and clinics that developed in response to the PPE shortage earlier this spring, as an example of how THA members can communicate and collaborate across member hospitals for a greater purpose. The PPE Sharing Network has been especially beneficial for rural areas, where transportation costs and distance are serious barriers to health care.
“This is an opportunity for Texas to move forward,” said Dr. Parnell, “We must all unite around this pandemic of disparities and injustice in health care, similar to what we are doing with the coronavirus pandemic. We must have a sustainable action plan with measurable goals as we move forward and recognize this is going to be a journey.”
Cotton says that the work required to make improvements will be very difficult, but that it is well worth it, likening the experience to working out and getting in shape. “There are going to be some challenging conversations. They’re going to hurt a little bit. The only way to build up muscle is to tear it down. And we’re in that process now so we can build back up and be stronger.”