Driving Health Equity Into Action: The Potential of Health Equity Impact Assessment<br />Bob Gardner<br />Diversity and Eq...
Starting Points<br />health disparities in Ontario and Canada are pervasive and damaging<br />but these disparities can be...
Outline<br />set the scene: <br />challenge of systemic health inequities <br />potential of health equity strategy to add...
The Challenge: Systemic Health Disparities<br /><ul><li>there is a clear gradient in health in which people with lower inc...
plus major differences between women and men
in addition, there are systemic disparities in access to and quality of care within the healthcare system
not just unfair and unjust, but health disparities make it more difficult to achieve provincial priorities such as ALCs, E...
enhancing health equity has become a clear priority – from the Province to LHINs to many providers
that’s why we need strategies, tools and best practices to build equity into effective system and service planning</li></u...
© The Wellesley Institute<br />www.wellesleyinstitute.com<br />5<br />
Social Gradient of Health: Depression<br /><ul><li>lowest-income neighbourhoods had a significantly higher prevalence of p...
+ inequitable service use:</li></ul>people living in the lowest-income neighbourhoods were somewhat more likely to use men...
7<br />
Impact of Disparities<br />inequality in how long people live<br />difference btwn life expectancy of top and bottom incom...
9<br />www.welleseyinstitute.com<br />Foundations of Health Disparities Roots Lie in Social Determinants of Health <br /><...
impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and...
real problem is differential access to these determinants – many analysts are focusing more specifically on social determi...
SDoH As a Complex Problem<br /><ul><li>Determinants interact and intersect with each other
In constantly changing and dynamic system
In fact, through multiple interacting and inter-dependent economic, social and health systems
Determinants have a reinforcing and cumulative effect on individual and population health</li></ul>11<br />
POWER Study<br />Gender and<br />Equity<br />Health Indicator<br />Framework<br />12<br />
Three Cumulative and Inter-Dependent Levels Shape Health Inequities<br />because of inequitable access to wealth, income, ...
Health Equity = Reducing Unfair Differences<br /><ul><li>Health disparities or inequities are differences in health outcom...
This concept:
is clear, understandable and actionable
identifies the problem that policies will try to solve
is also tied to widely accepted notions of fairness and social justice
The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities a...
A positive and forward-looking definition = equal opportunities for good health
Equity is a broad goal, including diversity in background, culture, race and identity</li></ul>14<br />
15<br />Think Big, But Get Going<br /><ul><li>health disparities can seem so overwhelming and their underlying social dete...
think big and think strategically, but get going</li></ul>make best judgment from evidence and experience<br />identify ac...
unless we address inequitable access and quality, healthcare and health promotion could make overall disparities even worse
at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social posit...
<ul><li>goal is to ensure equitable access to high quality healthcare regardless of social position
through a multi-pronged strategy:</li></ul>building health equity into all health care planning and delivery<br />doesn’t ...
Equity Into Health System: How II<br />while health disparities are pervasive and deep-rooted, they can be changed through...
Start From The Community<br /><ul><li>goal is to reduce health disparities and speak to needs of most vulnerable communiti...
can’t just be ‘experts’, planners or professionals
have to build community into core planning and priority setting
not as occasional community engagement
but to identify equity needs and priorities
and to evaluate how we are doing
how:
many hospital have community advisory panels
CHCs and many other providers have community members on their boards
innovative methods of engagement – e.g. citizens’ assemblies or juries in many countries
community-based research, needs assessment and evaluation</li></ul>19<br />
Align with System Drivers and Trends: ECFA Act and Quality Agenda<br /><ul><li>Quality Improvement Plans</li></ul>hospital...
Into Practice Through Equity-Focused Planning<br /><ul><li>addressing health disparities in service delivery requires a so...
key barriers to equitable access to high quality care
the specific needs of health-disadvantaged populations
gaps in available services for these populations
need to understand roots of disparities:
i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular nei...
which requires good local research and detailed information – speaks to great potential of community-based research
involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real l...
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Driving Health Equity into Action: The Potential of Health Equity Impact Assessment

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This presentation provides a critical analysis of the potential of a health equity impact assessment.

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

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  • these damaging disparities = the problem we are trying to solvethese disparities + and their impact on people&apos;s ability to cope with health challenges = vital part of the context for all health, home and related service delivery
  • mental health is crucial component of overall well-being – also major provincial prioritysame social gradient of mental health
  • OHIP core services
  • Getting specific on concrete impact of health disparities on quality of livesactivities of ¼ of low income people are limited by pain = 2X than high income
  • In: that&apos;s impact on daily livesthat type of impact adds up over people&apos;s livesesp.. impt in this context – home and community services deal with the impact of chronic conditions and inequitable morbidity
  • reinforcing nature of social determinants on health disparities = complex problemsignificance for key priorities = crucial part of managing diabetes and other chronic conditions is good nutrition need to assess this and other facets of people’s living conditions and resources for case management and planning – what % of mw clients face food insecurityneed to customize services to meet complex and often more challenging needs of disadvantaged populations
  • this complexity is felt on the ground at program levelhighlights need to drill down to identify underlying basis of problems introduce term if needed to further illustrate complexity of landscape? inter-sectionality – reflecting the fact that personal identities, group dynamics and relations of power and opportunity do not reflect a single line of oppression/identity such as gender, race or class, but their reinforcing and interacting nature
  • another way of looking at this complexity and what to do about itcommunity resilience and capacities operates at key intersections herethis highlights that SDoH can be driven into action on the ground through:community-based development or capacity building e.g. community development workers in many CHCscross-sectoral collaborations – many local mh groups and networkscross-sectoral planning tables and processesto drive local coordinated action e..g comprehensive community initiatives such as Vibrant Communities or common pattern in European health equity strategies of concentrated/coordinated local investment/focusa central issue is how to build mental health into all that
  • Principle applies throughout system – at provider and often at program level as well
  • practical local example – esp. impt to UHN
  • In: start from solid strategic commitment – which you haveopenings: providers and LHINs are mandated to undertake community engagement
  • Sick Kids analysis of patients by neighbourhood income levelneed to match tools to purpose
  • need to match tools to purpose can adapt to particular care and disciplinary settings
  • tool --- better to think of as a process
  • where workbook comes in:provides definitions, examples, prompts and possible questionsis set up to help users work through the HEIA process in a step-by-step wayusers simply fill out the appropriate tables in workbook itself to complete their HEIAthe workbook was designed so it can be adapted to become a Web-based interactive resource
  • highlights looking for unintended consequences
  • which is equity-orientated by def’nthis is about need to drill down to complexities and specifics
  • which is equity-orientated by def’nthis is about need to drill down to complexities and specificsfor place-based = need to take account of built and social environment
  • variations would not just be unfair, but contribute to avoidable complications – quality issue – and costspart of bigger picture:here also would drill down at scoping stage to specify the problem:variations in treatment?are there variations in outcomes – immediate success of treatment, longer-term recovery, morbidity, re-admissions?
  • Step 2 – identifying possible impactsevidence tells us what does that meanStep 3 -- identifying possible mediating or remedial actionson the face of it, not much hospitals and other providers can do about social conditions?but drilling down, can actthese remedial actions seem beyond hospital mandatebut what if relatively modest costs and programs reduced re-admission and attendant costs?Sick Kids partnership with Law Society to provide landlord, legal and other support for poor families – assuming this will support children’s healthrole for LHINs in just this kind of experiment and innovation?
  • Step 2 – identifying possible impactsevidence indicates a fairly obvious implicationwhat else?any access barriers?Step 3 -- identifying possible mediating or remedial actionsbut drilling down, can act
  • many experts see recs for action as critical stage – no point in identifying inequitable impacts if nothing is going to be doneStep 4 -- monitoring impacts -- need to think about that as part of HEIA process and set up evaluation mechanisms from the start
  • recognizing that what gets measured, matters
  • if time is tight – end hereif not, skip
  • a few illustrative questions for eachwould need to drill down even deeper in working group
  • Driving Health Equity into Action: The Potential of Health Equity Impact Assessment

    1. 1. Driving Health Equity Into Action: The Potential of Health Equity Impact Assessment<br />Bob Gardner<br />Diversity and Equity in Mental Health Conference<br />May 27, 2011<br />
    2. 2. Starting Points<br />health disparities in Ontario and Canada are pervasive and damaging<br />but these disparities can be addressed through comprehensive health equity strategy<br />equity strategy can be driven into action within the health system through<br />equity-focused planning<br />aligning equity with key system drivers such as sustainability and quality, and priorities such as ER, ALC, mental health, etc.<br />building equity into ongoing performance management and service delivery<br />investing in promising interventions, and pulling them together within a coherent and coordinated overall strategy<br />enabling innovation through sharing and building on front-line and local initiatives, evaluation, and organizational learning<br />focus today is on a key setting for implementing this overall strategy -- equity-focused planning and delivery of community-based mental health – using HEIA<br />2<br />
    3. 3. Outline<br />set the scene: <br />challenge of systemic health inequities <br />potential of health equity strategy to address them<br />one pre-condition of an effective strategy is equity-focused planning<br />and one useful tool is Health Equity Impact Assessment<br />will sketch out background and potential of HEIA<br />will work through several concrete planning scenarios<br />3<br />
    4. 4. The Challenge: Systemic Health Disparities<br /><ul><li>there is a clear gradient in health in which people with lower income or socio-economic status, or facing discrimination, racism or other lines of social exclusion, tend to have poorer health
    5. 5. plus major differences between women and men
    6. 6. in addition, there are systemic disparities in access to and quality of care within the healthcare system
    7. 7. not just unfair and unjust, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs
    8. 8. enhancing health equity has become a clear priority – from the Province to LHINs to many providers
    9. 9. that’s why we need strategies, tools and best practices to build equity into effective system and service planning</li></ul>4<br />
    10. 10. © The Wellesley Institute<br />www.wellesleyinstitute.com<br />5<br />
    11. 11. Social Gradient of Health: Depression<br /><ul><li>lowest-income neighbourhoods had a significantly higher prevalence of probable depression than highest-income neighbourhoods
    12. 12. + inequitable service use:</li></ul>people living in the lowest-income neighbourhoods were somewhat more likely to use mental health services and to receive ECT<br />much more likely to be hospitalized for depression<br />however, individuals living in the lowest-income neighbourhoods accounted for lower mental health care costs, which suggests they either made fewer visits or received less expensive services than those living in the highest-income neighbourhoods.<br />Source: POWER Study Vol 1 Exhibit 5a.9<br />6<br />
    13. 13. 7<br />
    14. 14. Impact of Disparities<br />inequality in how long people live<br />difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for women<br />+ inequality in how well people live:<br />more sophisticated analyses add the pronounced gradient in morbidity to mortality -> taking account of quality of life and developing data on health adjusted life expectancy<br />even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women <br />Statistics Canada Health Reports Dec 09<br />8<br />
    15. 15. 9<br />www.welleseyinstitute.com<br />Foundations of Health Disparities Roots Lie in Social Determinants of Health <br /><ul><li>clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion
    16. 16. impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes is well established here and internationally
    17. 17. real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities</li></li></ul><li>Canadians With Chronic Conditions Who Also Report Food Insecurity<br />10<br />
    18. 18. SDoH As a Complex Problem<br /><ul><li>Determinants interact and intersect with each other
    19. 19. In constantly changing and dynamic system
    20. 20. In fact, through multiple interacting and inter-dependent economic, social and health systems
    21. 21. Determinants have a reinforcing and cumulative effect on individual and population health</li></ul>11<br />
    22. 22. POWER Study<br />Gender and<br />Equity<br />Health Indicator<br />Framework<br />12<br />
    23. 23. Three Cumulative and Inter-Dependent Levels Shape Health Inequities<br />because of inequitable access to wealth, income, education and other fundamental determinants of health -><br />also because of broader social and economic inequality and exclusion-><br />along very similar lines, disadvantaged and vulnerable populations face systemic barriers within the health and other systems -><br />gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions<br />some communities and populations are more vulnerable and have fewer capacities, resources and resilience to cope with the impact of health inequities<br />these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need<br />13<br />
    24. 24. Health Equity = Reducing Unfair Differences<br /><ul><li>Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage
    25. 25. This concept:
    26. 26. is clear, understandable and actionable
    27. 27. identifies the problem that policies will try to solve
    28. 28. is also tied to widely accepted notions of fairness and social justice
    29. 29. The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes
    30. 30. A positive and forward-looking definition = equal opportunities for good health
    31. 31. Equity is a broad goal, including diversity in background, culture, race and identity</li></ul>14<br />
    32. 32. 15<br />Think Big, But Get Going<br /><ul><li>health disparities can seem so overwhelming and their underlying social determinants so intractable -> can be paralyzing
    33. 33. think big and think strategically, but get going</li></ul>make best judgment from evidence and experience<br />identify actionable and manageable initiatives that can make a difference<br />experiment and innovate <br />learn lessons and adjust – why evaluation is so crucial <br />gradually build up coherent sets of policy and program actions – and keep evaluating<br /><ul><li>need to start somewhere – and focus here is on building equity into best mental health promotion and care</li></li></ul><li>even though roots of health disparities lie in far wider social and economic inequality<br />it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care<br /><ul><li>equitable healthcare and proactive health promotion can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities</li></ul>in addition, there are systemic disparities in access and quality of healthcare that need to be addressed<br /><ul><li>people lower down the social hierarchy tend to have poorer access to health services, even though they may have more complex needs and require more care
    34. 34. unless we address inequitable access and quality, healthcare and health promotion could make overall disparities even worse
    35. 35. at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social position</li></ul>Equity Into Health System: Why <br />16<br />
    36. 36. <ul><li>goal is to ensure equitable access to high quality healthcare regardless of social position
    37. 37. through a multi-pronged strategy:</li></ul>building health equity into all health care planning and delivery<br />doesn’t mean all programs are all about equity<br />but all take equity into account in planning their services and outreach<br />aligning equity with system drivers and priorities<br />embedding equity in provider organizations’ deliverables, incentives and performance management <br />targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers<br />looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable<br />while thinking up-stream to health promotion and addressing the underlying determinants of health<br />Equity Into Health System: How<br />17<br />
    38. 38. Equity Into Health System: How II<br />while health disparities are pervasive and deep-rooted, they can be changed through policy and program action<br />comprehensive strategy developed in 2008 for Toronto Central LHIN<br />many recommendations have been acted on<br />other LHINs are also prioritizing and moving to address health disparities <br />18<br />
    39. 39. Start From The Community<br /><ul><li>goal is to reduce health disparities and speak to needs of most vulnerable communities – who will define?
    40. 40. can’t just be ‘experts’, planners or professionals
    41. 41. have to build community into core planning and priority setting
    42. 42. not as occasional community engagement
    43. 43. but to identify equity needs and priorities
    44. 44. and to evaluate how we are doing
    45. 45. how:
    46. 46. many hospital have community advisory panels
    47. 47. CHCs and many other providers have community members on their boards
    48. 48. innovative methods of engagement – e.g. citizens’ assemblies or juries in many countries
    49. 49. community-based research, needs assessment and evaluation</li></ul>19<br />
    50. 50. Align with System Drivers and Trends: ECFA Act and Quality Agenda<br /><ul><li>Quality Improvement Plans</li></ul>hospitals just developed first generation and will be reporting every year <br />opportunity = equity can be built in as one of dimensions to report on<br />other provider institutions will be reporting in future<br /><ul><li>quality and patient-centred care:</li></ul>taking lived conditions/experience into account – meaning equity and diversity -> essential to high quality patient-centred care for all<br /><ul><li>chronic disease prevention and management is major prov priority</li></ul>context for you – many clients will have concurrent challenges?<br /><ul><li>equity as contributing to cost-effectiveness and safety:</li></ul>e.g. reducing language barriers to good care through better interpretation can reduce mis-diagnoses and over-prescriptions -> enhanced quality and cost effectiveness<br />20<br />
    51. 51. Into Practice Through Equity-Focused Planning<br /><ul><li>addressing health disparities in service delivery requires a solid understanding of:
    52. 52. key barriers to equitable access to high quality care
    53. 53. the specific needs of health-disadvantaged populations
    54. 54. gaps in available services for these populations
    55. 55. need to understand roots of disparities:
    56. 56. i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc.
    57. 57. which requires good local research and detailed information – speaks to great potential of community-based research
    58. 58. involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems
    59. 59. requires an array of effective and practical equity-focused planning tools</li></ul>21<br />
    60. 60. Equity-Focused Planning Tools<br />quick check to ensure equity is considered in all service delivery/planning<br />take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery<br />assess current state of provider organization<br />determine needs of communities facing health disparities <br />assess impact of programs/interventions on health disparities and disadvantaged populations<br />simple equity lens<br />Health Equity Impact Assessment<br />equity audits and/or HEIA<br />equity-focused needs assessment<br />equity-focused evaluation<br />22<br />
    61. 61. Health Equity Impact Assessment<br /><ul><li>analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations</li></ul>generally designed for planning forward <br />as easy-to-use tool to ensure equity factors are taken into account in planning new services, policy development or other initiatives<br /><ul><li>but experience here and in other jurisdictions identified other uses:</li></ul>for strategic and operational planning<br />for assessing whether programs should be re-aligned or continued<br />more generally, discussions around HEIA provide a way to ensure equity is incorporated into routine planning throughout an organization<br /><ul><li>increasing attention to this potential – from WHO, through most European strategies, PHAC, to Ontario</li></ul>23<br />
    62. 62. HEIA In Ontario<br /><ul><li>first piloted and refined in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI, and in several LHINs afterwards
    63. 63. final version of template and workbook released by Ministry in 2011 see their page at http://www.health.gov.on.ca/en/pro/programs/heia/background.aspx
    64. 64. growing use within health:</li></ul>HEIA is being used in Toronto Central and other LHINs <br />by many hospitals and other providers across Toronto<br />Toronto Central has required HEIA within recent funding application processes for Aging at Home, and refreshing hospital equity plans<br />primers on HEIA and a variant Mental Health Wellbeing Impact Assessment, many Wellesley workshops and other resources can be found on page at http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment<br /><ul><li>Equity Assessment Framework being developed and piloted by the Ontario Agency for Health Protection and Promotion</li></ul>24<br />
    65. 65. HEIA Into Practice: Lessons Learned<br /><ul><li>from implementation so far and many workshops – can’t be prescriptive in using tool</li></ul>doesn't matter so much what kind of document results<br />real value is pulling people together to plan and analyze equity<br />real impact comes from using HEIA to help embed equity into the working culture of organizations<br /><ul><li>another lesson learned is that effective implementation odes require capacities</li></ul>easier in large organizations with planning resources<br />but, even with limited resources and correspondingly more limited scope – can still be very useful exercise<br /><ul><li>need to realize that HEIA will serve different purposes in different organization depending upon their experience with equity planning and implementation</li></ul>May 30, 2011<br />25<br />
    66. 66. Lessons Learned II: Adjust Purposes and Use to Context<br /><ul><li>for LHINs and Province, HEIA is one lever to help:</li></ul>ensure equity is routinely taken into account in health care planning and delivery<br />equity gets embedded in providers’ organizational planning and practice<br />especially important for health service providers who are not experienced with equity<br /><ul><li>but for HSPs who are experienced and committed to equity or who work with disadvantaged populations, HEIA can help to:</li></ul>ensure the full complexities of community challenges and capacities are considered<br />identify sub-populations, specific barriers or other issues that can easily be missed<br />can help clarify assumptions – what is exactly is meant by community? what are the success conditions for the particular program in that particular community context?<br />26<br />
    67. 67. HEIA Into Practice: Five Stages<br />preliminary stage = scoping<br />could the policy or initiative have a differential or inequitable impact on different groups?<br />if yes, consider HEIA<br />analyze how the planned program or initiative affects health equity for particular populations<br />list of health disadvantaged populations – not exhaustive<br />potential impact on social determinants of health<br />assess potential positive and negative impacts of the initiative on the population(s)<br />develop strategies to build on positive and mitigate negative impacts<br />plan how implementation of the initiative will be monitored to assess its impact<br />27<br />
    68. 68. MOHLTC 2011 HEIA Template<br />28<br />
    69. 69. Scoping the Issue Through an Equity Lens<br /><ul><li>simple equity lens that can be broadly applied =</li></ul>could the policy, program or initiative have a differential or inequitable impact on different groups?<br /><ul><li>use this for scoping stage = whether there are inequitable differences is a research question:
    70. 70. so, first action item from HEIA scoping = if we don’t know -> find out</li></ul>highlights importance of collecting better equity-relevant data across the system and by every provider as a priority<br />can use proxy data from postal code = neighbourhood characteristics from census data<br />can use case studies and small-scale interview/chart review studies<br />can rely on provider experience and community perceptions at this scoping stage<br /><ul><li>if evidence is yes -> then can drill down using HEIA template </li></ul>29<br />
    71. 71. Workshop Scenarios<br /><ul><li>We are establishing a new mental health promotion program in an immigrant community. How can we ensure it has the greatest equity impact?
    72. 72. We are developing a drop-in counselling and support program for people with mental health needs in a poor neighbourhood. The whole point is to provide better services to a disadvantaged community. But are there other factors we need to take into account?
    73. 73. There are higher rates to re-admission for psychiatric patients from a poor neighbourhood. What can be done? </li></ul>30<br />
    74. 74. Scenario I: Developing a Community-Based Mental Health Promotion Program in an Immigrant Community<br /><ul><li>drill down = what specific make-up of this immigrant community?</li></ul>legal status <br />some without OHIP?<br />history -- both of particular immigrant community and of individuals<br />specific contexts from which people came – war, conflict<br />what languages<br /><ul><li>what current socio-economic position?</li></ul>SDoH differences within community<br /><ul><li>what cultural differences/dynamics</li></ul>inter-generational differences?<br /><ul><li>translate material into appropriate languages</li></ul>take SDoH into account in service planning<br />needs assessment and gap analysis -> prioritize services/outreach<br />thinking about reach as well – who isn’t signing up or getting the services they need? <br /><ul><li>innovative options such as peer ambassadors
    75. 75. train partners, provide resources for capacity building</li></ul>31<br />
    76. 76. Scenario II: Developing a Drop-in Service in a Poor Neighbourhood<br /><ul><li>what make-up of this community?</li></ul>are all poor<br />what kinds of jobs?<br />diversity along ethno-cultural , language and immigration lines<br />what languages are spoken and preferred?<br />asset and strength-based, not just challenges and barriers<br /><ul><li>what SDoH differences within community
    77. 77. what physical, environmental and other issues need to be considered – e.g. few parks, rail line or highways?
    78. 78. what mental health and related health and social services currently exist?</li></ul>needs assessment and gap analysis <br />-> prioritize mix of services<br />->outreach to build on existing services and respected organizations<br />->where to base the new service that is most convenient and effective<br /><ul><li>translate material into appropriate languages</li></ul>take SDoH into account in service planning/delivery<br />thinking about reach as well – who isn’t signing up or getting the services they need? <br /><ul><li>innovative options such as peer ambassadors/navigators</li></ul>32<br />
    79. 79. Scenario III: Post-Treatment Psychiatric Re-Admission Rates<br />Hospitals have found that there is a higher rate of re-admissions for their psychiatric patients who live in Parkdale and other poor neighbourhoods. What can be done?<br /><ul><li>wider context = considerable attention to re-admissions:</li></ul>quality issue<br />clear pressure to reduce re-admissions – ties to ALC, ER and other priorities<br />May 30, 2011<br />33<br />
    80. 80. Coming Into Hospital for Psychiatric Treatment: Patients From Poor Neighbourhoods<br /><ul><li>population health and epidemiological data indicate that they may have poorer overall health </li></ul>-> greater risk <br />-> greater prevalence<br />+ less capacity to cope well with effects of mental illness<br /><ul><li>does this vary within the neighbourhood?</li></ul>by race, immigrant status, etc.<br /><ul><li>what community-based services are available in neighbourhood?</li></ul>are there access barriers to them – language, cost, accessibility?<br /><ul><li>can take poorer situations/higher risks into account:</li></ul>at least, ensure no differential or inequitable treatment<br />equitable care = more intensive pre-admission planning and support for those most in need<br />more intensive preventative and support programs in community<br /><ul><li>even broader = taking SDoH into account</li></ul> including child care, transportation and other assistance to support coming in for appointments<br />nutritional and other support<br /><ul><li>partner with community providers to ensure better support for people</li></ul>to promote mental health and reduce need for treatment<br />to enhance outcomes from treatments<br />May 30, 2011<br />34<br />
    81. 81. Post-Psychiatric Treatment: Patients From Poor Neighbourhoods<br /><ul><li>poor living conditions, food, anxiety -> less able to cope -> poorer recovery
    82. 82. can’t take as much time off work
    83. 83. can’t afford meds
    84. 84. don’t have equitable access to home and community-based support</li></ul>research question = is access and utilization equitable?<br /><ul><li>can take poorer situations/higher risks into account:</li></ul>at least, ensure no differential or inequitable treatment in (length of stay, intensity, etc)<br />equitable care = more intensive discharge planning, case mgmt and assessment<br />send home with more supplies, meds, etc.<br />more intensive follow-up to those in greatest need – socially as well as medically defined<br /><ul><li>partner with community-based providers and groups</li></ul>May 30, 2011<br />35<br />
    85. 85. HEIA Into Action<br /><ul><li>demonstrated value of equity lens on this issue – and most?
    86. 86. can identify inequitable constraints and barriers:</li></ul>in many cases, some seem outside of provider’s control <br />-> but can take into account in care planning<br />-> develop strategic partnerships<br />can identify mediating actions that can be taken and make recommendations:<br />to senior mgmt and appropriate care teams<br /><ul><li>then need to monitor impact:</li></ul>indicators and stats<br />patient satisfaction – by these equity variables<br /><ul><li>assess lessons learned -> incorporate into ongoing quality improvement</li></ul>May 30, 2011<br />36<br />
    87. 87. Specific Variant: MWIA<br /><ul><li>potential =</li></ul>contribute to more efficient and comprehensive planning that embeds mental health<br />can help build comprehensive view of mental well-being – dual continua approach<br />demonstrate importance of mental health to so many service and policy spheres -> transform working culture to take mental health into account<br /><ul><li>interest in Canada – </li></ul>PHAC has working group<br />will be exploring how to adapt MWIA model to Cdn context<br />May 30, 2011<br />37<br />
    88. 88. May 30, 2011<br />38<br />
    89. 89. Beyond Planning: Embed Equity in Performance Measurement and Management<br /><ul><li>clear consensus from research and policy literature and consistent feature in comprehensive policies on health equity from other countries =
    90. 90. setting targets for reducing access barriers, improving health outcomes of particular populations, etc
    91. 91. developing realistic and actionable indicators for service delivery
    92. 92. closely monitoring progress against the targets and indicators
    93. 93. disseminating the results widely for public scrutiny
    94. 94. tying funding and resource allocation to performance
    95. 95. what would equity-focused performance indicators, measurement and management look like for mental health?</li></ul>39<br />
    96. 96. Beyond Healthcare System: SDoH Into Action<br /><ul><li>have emphasized taking SDoH into account in service delivery and planning
    97. 97. more broadly, cross-sectoral coordination and planning are much emphasized in public health and health policy circles
    98. 98. addressing wider SDoH is the glue for collaboration into action
    99. 99. public health departments and LHINs are pulling together or participating in cross-sectoral planning tables
    100. 100. Local Immigration Partnerships , Social Planning Councils
    101. 101. comprehensive community initiatives to address poverty and other complex local problems
    102. 102. the Ministry of Health Promotion and Sport is developing a healthy communities strategic approach
    103. 103. cross-sectoral planning to ground health promotion
    104. 104. at best, this implies wider community development and capacity building approaches</li></ul>40<br />
    105. 105. Key Messages<br /><ul><li>health disparities are pervasive and deep-seated – but can’t let that paralyze us
    106. 106. do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy
    107. 107. think big and think strategically – but get going
    108. 108. build equity into strategic priorities, align with quality agenda and system priorities, embed in routine planning and performance management
    109. 109. and build equity into front-line planning and delivery where you practice
    110. 110. no magic blueprint -- experiment and innovate -- and build on learnings and success</li></ul>41<br />
    111. 111. Key Messages II<br /><ul><li>for both mental health – and health equity – we have solid evidence, know the challenges, and know the levers and drivers for change</li></ul>not perfect – but enough to act<br /><ul><li>to drive action, we need comprehensive and innovative strategy, but we also need focused planning
    112. 112. not just for effective implementation, but also to:</li></ul>raise awareness of mental well-being and equity as vital issues<br />embed and operationalize them in organizational structures and working cultures<br />build momentum for broad policy and social change<br />->where practical and actionable tools and processes come in <br /><ul><li>one promising and ready-to-go planning tool = Health Equity Impact Assessment -- experiment and innovate with it</li></ul>May 30, 2011<br />42<br />
    113. 113. Appendices<br /><ul><li>case study scenario: HEIA to a LHIN mental health strategy
    114. 114. drilling down to theory of change underlying equity-focused planning
    115. 115. Wellesley Health Equity Roadmap</li></ul>43<br />
    116. 116. Case Study: Using HEIA For TC LHIN Mental Health Strategy<br /><ul><li>the goal:</li></ul>ensure equity is adequately built into mental health strategy<br />ensure strategy addresses systemic barriers to access and quality care<br />ensure strategy will benefit most health disadvantaged populations<br />May 30, 2011<br />44<br />
    117. 117. 1: Scoping Who Is Affected<br /><ul><li>critical health disadvantaged pop’n
    118. 118. equity issues all along life-course– racialized youth, poor seniors
    119. 119. dynamics of concurrent challenges
    120. 120. impact of racism and social exclusion, non-insured, need for customized services
    121. 121. in TO? but newcomers, non -insured
    122. 122. absolutely
    123. 123. absolutely – and increasingly
    124. 124. critical importance of income inequality and poverty
    125. 125. place and isolation matters to mental health especially
    126. 126. gender – systemic differences and access
    127. 127. sexual orientation – well documented systemic discrimination and barriers</li></ul>May 30, 2011<br />45<br />
    128. 128. 2: Drilling Down on Impact<br /><ul><li>for each of the vulnerable populations affected
    129. 129. did the strategy sufficiently identify?</li></ul>the specific needs of these specific disadvantaged populations<br />the access and quality barriers they face?<br /><ul><li>unequal access to the social determinants of health and systemic barriers play out in people’s lives and in particular communities in cumulative, reinforcing and inter-dependent ways</li></ul>clinical language of concurrent disorders or academic language of inter-sectionality<br />was this complexity captured and built into strategy?<br />May 30, 2011<br />46<br />
    130. 130. 2: Drilling Down on Process<br /><ul><li>key goal = ensuring high-quality mental health services and continuum of support for all</li></ul>were those living with mental health challenges involved in defining what quality means to them?<br />were they involved in indicator and measurement discussions?<br /><ul><li>working backwards from ultimate goal = what would the best quality and continuum of care look like</li></ul>through an equity lens?<br />to these different populations – from their different perspectives?<br /><ul><li>were the voices of these different populations incorporated into planning process?</li></ul>May 30, 2011<br />47<br />
    131. 131. 3: Addressing Needs and Barriers<br /><ul><li>Aboriginal populations
    132. 132. homeless
    133. 133. poor/economically vulnerable more generally
    134. 134. newcomers and people facing language barriers
    135. 135. were Aboriginal providers/networks built into planning process?
    136. 136. are specific Aboriginal-driven services being planned?
    137. 137. were existing resources – CAISI, providers, networks, successful programs – built on?
    138. 138. cross-sectoral collaborations – health, shelter, social services
    139. 139. linking to poverty reduction strategies and advocacy
    140. 140. interpretation and translation
    141. 141. cultural competence + resources and management
    142. 142. funding to specialized ethno-cultural community groups</li></ul>May 30, 2011<br />48<br />
    143. 143. 4: Evaluation and Monitoring<br /><ul><li>evaluation goal = to figure out what works, in what contexts and, most importantly, how and why </li></ul>we break down our plan/strategy into stages to assess what happened<br />were key access barriers and service gaps identified and addressed?<br />were services planned and delivered effectively?<br />full range of different service models and settings<br />coordinated into seamless continuum of care<br />did service changes improve access and quality?<br />using clear quality and access indicators<br />and building in community voice – did identified populations think these services made a difference to their well being?<br />ultimately, was mental health of identified populations improved and were disparities reduced? <br />May 30, 2011<br />49<br />
    144. 144. Challenges of Equity-Focused Evaluation<br /><ul><li>Ministry, LHINs and research bodies need to fund and enable evaluation – not just as a tacked-on expectation in accountability regimes
    145. 145. need to figure our what interventions and approaches work, in what contexts and why
    146. 146. at a program as well as system level:
    147. 147. can’t just measure activity – number or % of pop’n that participated in a program or received particular services
    148. 148. need to measure health outcomes – even when impact only shows up in long-term
    149. 149. need to assess reach -- who isn’t signing up or getting the services they need?
    150. 150. need to differentiate those with greatest need = who programs most need to reach and keep to have an impact</li></ul>50<br />
    151. 151. Drilling Down: Our ‘Theory of Change”<br /><ul><li>‘realist’ evaluation approach has great potential:</li></ul>we break down our plan/strategy into stages to assess what happened<br />were key access barriers and service gaps identified and addressed?<br />were services planned and delivered effectively?<br />full range of different service models and settings<br />coordinated into seamless continuum of care<br />did service changes improve access and quality?<br />using clear quality and access indicators<br />and building in community voice – did identified populations think these services made a difference to their well being?<br />ultimately, was mental health of identified populations improved and were disparities reduced? <br /><ul><li>evaluation goal = to figure out what works, for whom, in what contexts
    152. 152. start from clear theory of how we think better planning will reduce health inequities</li></ul>51<br />
    153. 153. taking account of social constraints & conditions<br />not just individual programs but coordination, partnerships & collaboration<br />52<br />
    154. 154. enhanced access to primary care & health promotion for most disadvantaged <br />up-stream heath conditions & opportunities improve fastest for those in greatest need<br />53<br />
    155. 155. <ul><li>these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com
    156. 156. my email is bob@wellesleyinstitute.com
    157. 157. I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity</li></ul>Following Up<br />54<br />
    158. 158. Wellesley Roadmap for Action on the Social Determinants of Health<br />look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities;<br />address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long-term;<br />develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on;<br />act across silos – inter-sectoral and cross-government collaboration and coordination are vital;<br />set and monitor targets and incentives – cascading through all levels of government and program action;<br />55<br />
    159. 159. Wellesley Roadmap II<br />6 rigorously evaluate the outcomes and potential of program initiatives and investments – to build on successes and scale up what is working; <br />7 act on equity within the health system:<br />making equity a core objective and driver of health system reform – every bit as important as quality and sustainability;<br />eliminating unfair and inefficient barriers to access to the care people need;<br />targeting interventions and enhanced services to the most health disadvantaged populations;<br />8 invest in those levers and spheres that have the most impact on health disparities such as:<br />enhanced primary care for the most under-served or disadvantaged populations;<br />integrated health, child development, language, settlement, employment, and other community-based social services;<br />56<br />
    160. 160. Wellesley Roadmap III<br />9 act locally – through well-focussed regional, local or neighbourhood cross-sectoral collaborations and integrated initiatives;<br />10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities;<br />11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country;<br />12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective program and policy instruments, and into a coherent and coordinated overall strategy for health equity.<br />57<br />
    161. 161. © The Wellesley Institute<br />www.wellesleyinstitute.com<br />58<br />
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