1. Health Disparities: Beyond the Epidemiological Evidence
Presenter: John Fontanesi
Co-authors: Linda Hill, Jill Rybar, David Kopald, CDC
University of California, San Diego

2. Differences are Significant

3. …AND GROWING

4. …And Cost not an explanation

5. Proposed Reasons Patient Factors Clinic Factors
Lack of trust in Health Care System
Fear of “Research”
Doubts about vaccine efficacy
Health Literacy
Cultural barriers
Clinic Factors
Availability of Providers
Cultural competency
Lack of audit and feedback information
Dysfunctional System
Poor or non-existent automation

6. Examining the Health Center
Cultural competency
Access to care,
Hours of operation
Types of services/specialists available
Staff turnover
Congruence
Patient-Provider language
Patient-Provider conversation
Economic

7. Financial Stress Matters: Missed Opportunity Rates
Insolvent Facilities

8. … And staff turnover matters
CASA rates < 70%
% Annual
Staff
turnover

9. … But “structure” is too simple an explanation
CASA rates < 70%
CASA rates >85%%
% Annual
Staff
turnover

10. Recommended strategies to improve coverage rates
Provider prompts
Provider audit and feedback
Organizational change
STANDING ORDERS
PATIENT REMINDER/RECALL
IMMUNIZATION CHAMPION
SPECIAL CLINICS

11. Organizational Behavior
There is (and should be) an interaction between “client” and organization
Being “customer-centric” means adapting delivery strategies to client preferences
The implementation of generic strategies in specific settings should reflect the interaction between the specific organization and client

12. Patient-oriented and community-based approaches are used to reach target populations

13. Brief Examples: What 4 San Diego clinics have in common
Medical Director aggressive about vaccinations
Active QI Program
Multi-arm delivery strategy
Targeted case management
Reminder/recall (automated)
Combination of mass clinics and individual appointments
Standing Orders
Self administered + contractual Audit/feedback

14. How they are different Clinic A Multi-site, for profit
Upper middle class mixed ethnicity
Arrive by Car
Primary Payor: Managed Care
HEDIS audit
Clinic B
Rural Indian Health Center
Rural poverty
Some clients travel 60+ miles
Primary Payor: IHS
GPRA audit
Clinic C
FQHC
Urban-impoverished
Hispanic Immigrants
Walk to clinic
Primary payor: Multiple/HRSA
Clinic D
FQHC
Suburban-lower SES
Hispanic-American
Drive or take Bus to clinic
Primary payor: Multiple/HRSA

15. Clinic A: Implementing Patient and Community Based Approaches
Emphasize client convenience
Vaccinate at Mass clinics
Vaccinate at local business, churches and schools
Active case management for Diabetes
Purchased and administered influenza 8500 dosages
4300 at “alternative" sites
No or low cost
No documentation
HEDIS Client satisfaction rating over 98%
HEDIS ALL “high risk young adult” coverage rate=42%
HEDIS Diabetic Coverage rate = 87%
HEDIS “senior” rate = 47%
Clinical Encounter coverage rate= 42%

16. Clinic B: Implementing Patient and Community Based Approaches
Emphasize respect for community elders
Prioritized vaccination strategy
Elders on reservation
Diabetics on reservations
Reservation members attending clinic
Rural Indians attending clinic
Urban Indians attending clinic
Purchased and administered influenza 600 dosages
Patient chart travels to reservation
GPRA “senior” coverage rates = 95%
GPRA Diabetics coverage rates = 78%
Clinical encounter coverage rates = 48%

17. Clinic C: Implementing Patient and Community Based Approaches
Emphasize Family
Vaccinate adults accompanying children
“Walk-in” Vaccination clinic
Low cost “Saturday” clinics
Active Case Management for Asthmatics
Purchased and administered influenza 1300 dosages
HEDIS “Senior” coverage rates = 84%(Grandma’s better then Grandpa's)
Asthmatic coverage rates = 86%
Clinical encounter coverage rates = 56%

18. Clinic D: Implementing Patient and Community Based Approaches
Emphasize “working poor”
Mass weekend Clinics
$2 “donation”
Vaccinate at all eligible scheduled appointments
Active Case Management for several “high risk” populations
“Senior” coverage rates = 84%
“At risk” coverage rates = 86%%
Clinical encounter coverage rates = 74%

19. Organizational Behavior
There is (and should be) an interaction between “client” and organization
Being “customer-centric” means adapting delivery strategies to client preferences
The implementation of generic strategies in specific settings should reflect the interaction between the specific organization and client
The decisions will impact relevant performance outcomes

20. Conclusions
Population-based and Clinic-based coverage rates are related but not the same
Patient and Provider characteristics may not be as important as infrastructure
Global strategies take on local context
Measurement may not always be aligned with local context

21. Conclusions
Some combination of working from the outside in (Rochester model) and the inside out (San Diego model) can mitigate disparities in health care settings
Work on understanding what works rather then concentrate on understanding failures