A Health Equity Toolkit:
Towards Health Care Solutions
For All
Bob Gardner
Solutions: East Toronto’s Health Collaborative
...
Problem to Solve:
Systemic Health Inequities in Ontario
clear gradient in health in
which people with lower
income, educat...
Gradient of Health Across Many
Conditions

3
Inequitable Quality
• from a resident participating in Wellesley communitybased research in St James Town

“Language is a ...
Health Equity
•

•
•

goal of health equity strategy is to reduce or eliminate socially and
institutionally structured hea...
Towards Health Equity Solutions
will set out a toolkit of ideas, directions
and techniques to build equity into
healthcare...
Today
equity toolkit
• most ideas/initiatives will be familiar
• but the great potential of networks like this is to ident...
1. Start from Solid Foundations
•

high-performing healthcare systems build equity into all planning
and service delivery
...
2. Into Practice Through Equity-Focused
Planning
• addressing disparities in access to or quality of health care
requires ...
Tools: Always Plan through a Health Equity Lens
Could this program or policy have a
differential and inequitable impact on...
• analyzes potential impact of program or policy change on health
disparities and/or health disadvantaged populations
• us...
3. Success Condition = Collect Equity Data
need solid equity-orientated data
• to identify gaps and needs of
disadvantaged...
4. Build Knowledge We Can Act On
base includes:
•
epidemiological research – scale of
disparities, disadvantaged
communiti...
5. Beyond Planning: Embed Equity Into Targets,
Deliverables and Performance Management
• clear consensus from research and...
Success Condition = Effective Equity Targets
• innovative work underway to develop comprehensive equity
indicators – but d...
6. Embed Equity Into Organizational and
System Drivers
• quality improvement is major provincial and system priority → emb...
Use Proven Tools: Equity Standards

Canadian Health Equity Standards Working
Group

17
7. Use Available Levers To Embed Equity
• key priority for Ministry (therefore LHIN) and great potential to
transform syst...
8. Target Access and Quality Barriers
improving equity requires identifying and addressing specific
equity barriers
• with...
9. Barrier = Under-Served Populations
Solution = Focused Community Partnerships
given often higher care needs and
less acc...
10. Shifting the Policy Frame:
Health = Healthy and Equitable Communities
what if hospital leaders said: we’re
not the mos...
Pull All This
Together into a Strategic
Roadmap
is there value in Solutions
developing an equity plan?
• what mbrs will do...
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A Health Equity Toolkit: Towards Health Care Solutions For All

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This presentation offers health solutions that will help create a more equitable system.

Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI

Published in: Health & Medicine, Business
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  • POWER data age-standardized % of adults 2005self-reported = good proxy for clinical outcomes but exactly the point here, capturing people’s experience of their healthtwo things here, you have in your backgrounder:consistent gradient of health – however measuredhuge and damaging differences – 3 X as many low income as high report health to be only fair or poor difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for womenmore sophisticated analyses add the pronounced gradient in morbidity to mortality -> taking account of quality of life and developing data on health adjusted life expectancyeven higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women Statistics Canada Health Reports Dec 09
  • specifying the problem to solveissues that span health system: health promotion from PH and others is crucial, acute when people get sick+ big focus of HL: co-morbidities, complex conditions this and other data shows burden and risk is highly inequitableone of most pressing system challenges everywhere = getting better balance btwn up-stream preventative and treatmentOnt 2005 age standardized 25>
  • lot of bad things in there:aside from access to care being effectively deniedgoing to emerg -> inappropriate care + avoidable costscouldn’t follow doc -> poor quality + danger
  • context of Excellent Care for All Act
  • you know local context – you will know best how to adaptbut do want to set out fairly full repertoire of strategies and programs – and success conditions for implementing
  • 2 sum is greater than parts
  • need to match tools to purpose
  • some CHCs, PHUs, etc. have used version of this kind of lens for years
  • increasing attention to this potential – from WHO, through most European strategies, PHAC, to Ontarioquandary: don't reify planning tools do want this to contribute to better equity-focused planningbut better to think of as a process – as a tool to facilitate conversations and analysis about equityas a catalyst for analysisless worried about documentation that resultssecond practical quandary:people in the field say it is too difficult to do thoroughlyit is difficult to find consistent data on all the population categories and determinants to be considereddon’t be paralyzed by lack of data – draw on local community and practice leaders also for evidence of potential impactincreasing emphasis on rapid desk-top assessmentsagain, think facilitating tool rather than producing solid evidence
  • 2 things about cover: equity = good for health and why data is neededquandary again: don’t get paralyzed by inconsistent/inadequate datastart to collectthink of base of data that will be available in 5 yearsesp. crucial given loss of census data – cant do neighbourhood proxy analysis as wellif time permits: having equity needs data will be impt as MOHLTC moves to more quality or performance-based funding
  • OWHN inclusion research model – peer
  • Out: recognizing that what gets measured, matters
  • satisfaction/communications is anotherenable all voices to be heard e.g. NRC Picker survey has been translated into several languageshighlights importance of aligning equity with key org/system priorities
  • all the organizational and delivery changes needed to drive QI = potential to transform healthcare systemkey challenge = how to ensure that quality improvement really does deliver For All
  • background on project – WHO, pilots here, this was Cdn Consortium, starting with hospitals, symposium in spring stay tunedstds as tool to identify key directions and levers for operationalizing equity plan – what needs to be lined up to drive change across all these fronts? how to dovetail constituent projects?monitor – develop indicators and targets for each componentfor facilitating equity conversations -- how well are we doing on these key components?
  • theme = use existing levers
  • all these barriers also suggest solutionslonger opening hours of clinicschildcare in hospitalsproviding care in people’s homes or community settings
  • lower cancer screening rates in particular ethno-cultural or disadvantaged groupse.g. South Asian women in Peel-> community-based research to assess why-> broad partnerships of Public Health, providers and trusted community organizations to get beyond barriers-> outreach to diverse community settings where women live, work or go
  • also key to policy change on SDoH is broader public awareness and mobilization lots of work underway on how to popularize and promote SDoH RWJ, NCCDH, videos Ryan Meili book and new collaborative called Upstreamat the same time, what language could help to pull together diverse work? could be focus on creating foundations of healthy communities
  • A Health Equity Toolkit: Towards Health Care Solutions For All

    1. 1. A Health Equity Toolkit: Towards Health Care Solutions For All Bob Gardner Solutions: East Toronto’s Health Collaborative January, 2014
    2. 2. Problem to Solve: Systemic Health Inequities in Ontario clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health the gap between the best off and most disadvantaged can be huge – and damaging however measured -- by particular conditions, quality of life, life expectancy 2
    3. 3. Gradient of Health Across Many Conditions 3
    4. 4. Inequitable Quality • from a resident participating in Wellesley communitybased research in St James Town “Language is a big barrier to us whenever we use any services. When our doctor is on leave then we are unable to visit a different one due to language problem. So we may have to go to a walk-in clinic or emergency. There were no interpreter services. I do not know if they arrange them in hospitals. I couldn’t follow what the doctor said.” 4
    5. 5. Health Equity • • • goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes positive and forward-looking definition = equal opportunities for good health operationalizing equity in health care = providing care to meet different needs of different patients and populations, in ways that reduce inequitable differences in outcomes: • understanding and addressing barriers to good care such as language and misunderstanding/discrimination • recent immigrants need care that respects their cultures and preferences and adjusts to their often more precarious economic situation • understanding and addressing living conditions and social context of patients • poorer people face greater burdens and constraints on opportunities for good health = need to take into account in care planning February 11, 2014 | www.wellesleyinstitute.com 5
    6. 6. Towards Health Equity Solutions will set out a toolkit of ideas, directions and techniques to build equity into healthcare planning and delivery • solidly based in research evidence and years of best practice • action-orientated and manageable • measureable – so can monitor and assess progress • adaptable to specific organizational and local contexts • and can use to act well beyond health system -- tackling the underlying roots of health inequality in the wider social determinants of health the particularly good news = don’t need to start from scratch 6
    7. 7. Today equity toolkit • most ideas/initiatives will be familiar • but the great potential of networks like this is to identify communitylevel challenges and opportunities, and to pull initiatives and elements together into a coherent overall equity strategy was thinking of toolkit in three ways for Solutions: 1. some parts of the toolkit can be adapted in your organization and sector – where you’re a champion at organizational level 2. some can help plan collaborative actions – potential of connected local initiatives 3. some are about identifying broader systemic and policy issues -- adding your collective voice to efforts to shift policy or framing of equity at system level will speculate on a few ideas and directions Solutions could consider 7
    8. 8. 1. Start from Solid Foundations • high-performing healthcare systems build equity into all planning and service delivery • • • need clear strategic commitment to build equity into system as a whole • • • • doesn’t mean all programs are all about equity does mean all programs and planning need to take equity into account LHIN, Ministry cascading throughout all providers and programs so that equity becomes part of working culture across the system commitment has to be backed up by resources for equity planning and operationalization role for Solutions? – mbrs promoting this goal of embedding across all their organizations and work | www.wellesleyinstitute.com 8
    9. 9. 2. Into Practice Through Equity-Focused Planning • addressing disparities in access to or quality of health care requires a solid understanding of: • the contours and scale of inequitable outcomes • the specific needs of health-disadvantaged populations • gaps in available services for these populations • key barriers to equitable access to high quality care along patient journey • at delivery level = considering equity in all program planning • e.g. given importance of communications and understanding to quality care → need to ensure cultural competence, access to interpretation wherever needed, etc. • need effective and practical equity-focused planning tools 9
    10. 10. Tools: Always Plan through a Health Equity Lens Could this program or policy have a differential and inequitable impact on some populations or communities? How do we need to take the specific needs of disadvantaged individuals and communities into account in planning and delivering this service? Role for Solutions? Advocate that all their member organizations use this type of basic equity lens routinely – from strategic to service planning if this basic equity lens indicates there could be inequitable impact → then could drill down using fuller HEIA Role for Solutions? Promote/enable use of HEIA within its organizations February 11, 2014 | www.wellesleyinstitute.com 10
    11. 11. • analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations • using HEIA can help • uncover unintended consequences or nuances easily missed in program planning • embed equity into routine planning processes and working culture • ensure that projects not specifically about equity or particular populations, will take language, diversity, local community conditions, etc. into account • especially important for health service providers who are not experienced with equity and for non-health organizations to take the population health impact of their policies into account • growing, if uneven, use: • across LHINs -- Toronto Central has required HEIA within recent funding application processes, and refreshing hospital equity plans → some hospitals have built HEIA into their routine planning processes • adaptation geared to public health settings and standards been developed and promoted by Public Health Ontario 11
    12. 12. 3. Success Condition = Collect Equity Data need solid equity-orientated data • to identify gaps and needs of disadvantaged patients • to measure and monitor progress pilot project in 3 Toronto hospitals (and Toronto Public Health) to collect patient SDoH type data scaled up to all hospitals in Toronto Central LHIN valuable website of resources on how to collect and use this data role for Solutions: all members to adapt data collection model to their situations, as standardized as possible → building pool of SDoH data 12
    13. 13. 4. Build Knowledge We Can Act On base includes: • epidemiological research – scale of disparities, disadvantaged communities/groups, community health profiles • community-based research = especially unique understanding of needs and interests of marginalized or excluded populations • evaluation –what works, for which populations, in varying contexts • need forums to share lessons learned, emerging practices systematic data collection + ability to measure/monitor /evaluate + broad research evidence = knowledge to guide/ground action role for Solutions? advocate for this broad understanding and bring solid community knowledge into planning
    14. 14. 5. Beyond Planning: Embed Equity Into Targets, Deliverables and Performance Management • clear consensus from research and policy literature, and consistent feature in comprehensive health equity policies and practice from other jurisdictions: • developing realistic and actionable indicators for more equitable service delivery and outcomes • setting targets for reducing access differentials, improving health outcomes of particular populations, etc • monitoring progress against the targets and indicators • disseminating the results widely for public scrutiny • aligning performance with funding incentives and resource allocation • principle here = build equity into system drivers and trends • performance measurement and management are here to stay • emerging challenge = building equity/population health into performance-based funding models 14
    15. 15. Success Condition = Effective Equity Targets • innovative work underway to develop comprehensive equity indicators – but don’t need to wait • pick what is most relevant to your context: • do rates of post-treatment recovery and hospital re-admission vary inequitably – by geography, ethno-cultural background, socio-economic status? → equity target = reduce inequitable differences • build equity into existing targets: • e.g. reducing hospital admission rates for ambulatory sensitive conditions and diabetes are system goals → equity target = reduce inequitable differences in rates between different populations or areas • role for Solutions? advocate within own organizations to build equity into scorecards and other performance measurement 15
    16. 16. 6. Embed Equity Into Organizational and System Drivers • quality improvement is major provincial and system priority → embed equity • patient-centred care + QI + equity = customized care to meet differing needs • social determinants disadvantaged populations face greater barriers beyond the hospital and clinic walls • availability/cost of transportation, childcare, poor living conditions, inequitable access to community services, discrimination, being able to afford medication → need more intensive case management, referral planning and postdischarge follow-up for those in more challenging/isolated conditions → effective continuum of care and effective navigation/transitions is especially important for marginalized • role for networks like Solutions? identifying what good linkages and comprehensive community support looks like for marginalized | www.wellesleyinstitute.com 16
    17. 17. Use Proven Tools: Equity Standards Canadian Health Equity Standards Working Group 17
    18. 18. 7. Use Available Levers To Embed Equity • key priority for Ministry (therefore LHIN) and great potential to transform system = Health Links • considerable debate about whether starting assumptions of heavy service users, etc., are right • but regardless of Min directions lots of innovative approaches on how to build SDoH in • role for Solutions? explore project on how these and other ideas could be developed into a comprehensive health equity toolkit for your Health Links • e.g. all HL to do community health mapping, identify priority and under-served populations, adapt tools for customized care for marginalized, develop explicit equity indicators, etc. • Solutions mbrs could take lead in promoting these tools and ideas in their HLs | www.wellesleyinstitute.com 18
    19. 19. 8. Target Access and Quality Barriers improving equity requires identifying and addressing specific equity barriers • within delivery – language, lack of understanding of different cultures, differential treatment, prejudice and discrimination, accessibility • beyond the clinical – e.g. sent home with follow-up prescriptions, but don’t have a drug plan; can’t come into clinic for follow-up because of family responsibilities • most important barriers will vary → back to importance of data and understanding health needs of community another Solutions’ focus for Health Links? • population health profiles, health equity audits, community engagement → to identify most important local barriers and gaps | www.wellesleyinstitute.com 19
    20. 20. 9. Barrier = Under-Served Populations Solution = Focused Community Partnerships given often higher care needs and less access to personal, family or community resources facing most marginalized: • effective follow-up and referrals and good continuity of care, navigation and transitions are even more impt for the most vulnerable • requires dense and connected web of community support role for Solutions? fulcrum to strengthen collaboration among community agencies through an equity lens • focused on particular populations or barriers
    21. 21. 10. Shifting the Policy Frame: Health = Healthy and Equitable Communities what if hospital leaders said: we’re not the most important drivers of good health and we’re going to work with others to build healthier communities. role for Solutions? policy advocacy for key local issues, adding voice to wider campaigns, system issues February 11, 2014 | www.wellesleyinstitute.com © The Wellesley Institute www.wellesleyinstitute.com 21
    22. 22. Pull All This Together into a Strategic Roadmap is there value in Solutions developing an equity plan? • what mbrs will do to promote equity in their home orgs • what network can do to identify most pressing common equity challenges and collaborative opportunities for change can’t be a rigid blueprint, needs to be adapted and implemented flexibly to contexts and circumstances • but thinking of equity roadmap helps to pull various initiatives into a coherent and connected plan

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