The California Endowment A Partner for Healthier Communities
Mobilizing to Eliminate  Health Disparities 2003 Ethnic Physician Summit Carolina Reyes, MD The California Endowment
<ul><li>Racial/Ethnic Disparities in Health </li></ul><ul><li>The IOM Report on Racial/Ethnic Disparities in Health Care: ...
<ul><li>Among the nation’s most serious health care problem (IOM 2002) </li></ul><ul><li>Approximately 30 percent of Ameri...
<ul><li>Despite health interventions that have improved the overall health of the majority of Americans, minorities have b...
Cardiovascular Disease  Death Rate, 1999 Deaths per 100,000 population
Cancer Death Rate, 1999 Deaths per 100,000 population
Diabetes-Related  Death Rate, 1999 Deaths per 100,000 population
<ul><li>Social Determinants </li></ul><ul><ul><li>Education, geography, environment, housing, employment </li></ul></ul><u...
<ul><li>Within Medicare: </li></ul><ul><ul><li>Differential utilization based on race for: </li></ul></ul><ul><ul><ul><li>...
<ul><li>Private, independent non-profit Institute of National Academy of Sciences </li></ul><ul><li>Examines issues relate...
<ul><li>Study Charge </li></ul><ul><li>Determine presence and extent of racial/ethnic disparities in health care  not attr...
<ul><li>Eliminating disparities in health has become a national priority of the NIH, DHHS </li></ul><ul><li>Any effort to ...
<ul><li>Neglecting study of the health impact of bias, discrimination means that explanations for and interventions to alt...
<ul><li>This area of work is fraught with controversy because the exposure raises important themes of accountability and h...
<ul><li>Explicitly naming a long-standing problem long recognized by those affected has the potential to galvanize or cata...
<ul><li>Once named it becomes less nebulous and more tangible </li></ul><ul><li>Bolstered with the belief that with more r...
Non-Minority Minority Difference Clinical Appropriateness  and Need  Patient Preferences   The Operation of Healthcare  Sy...
<ul><li>Sources of Data </li></ul><ul><li>Literature Search </li></ul><ul><ul><li>Over 600 papers reviewed </li></ul></ul>...
<ul><li>Major Finding </li></ul><ul><li>Racial/Ethnic disparities consistently found across a wide range of health care se...
<ul><li>Specific Findings </li></ul><ul><li>Racial and ethnic disparities in health care exist and, because they are assoc...
<ul><li>Specific Findings </li></ul><ul><li>Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthc...
“ Sociocultural differences between patient and physician influence  communications  and  clinical decision-making.”   Eis...
Linking Communication  to Outcomes <ul><li>How do we link communication to outcomes? </li></ul><ul><ul><li>Communication <...
“ Medical decision-making can be as much a function of  who the patient is  as much as  what the patient has. ” Mckinley e...
<ul><li>Focuses on questions such as: </li></ul><ul><ul><li>How do we develop perceptions and judgments of others? </li></...
<ul><li>Characteristics of the Patient </li></ul><ul><ul><li>Age, Sex, SES, Race/Ethnicity, Insurance, Individual patient ...
<ul><li>Automatic aspects; group  individual </li></ul><ul><li>“ Cognitive Misers”  cognitive shortcuts to save resource...
<ul><li>Built on the IOM report on Crossing the Quality Chasm in 2001 </li></ul><ul><ul><li>One of the six goals to raisin...
<ul><li>Arguments date back a century and a half ago </li></ul><ul><li>The task at hand is to bring the knowledge and meth...
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care   Institute of Medicine
<ul><li>Insanity is when we keep doing the same thing and expecting a different result. </li></ul><ul><li>-Albert Einstein...
<ul><li>Lack a robust tool bag of interventions </li></ul><ul><li>Significant disparity in the racial ethnic diversity amo...
<ul><li>General Recommendations: </li></ul><ul><li>Increase awareness of racial and ethnic  </li></ul><ul><li>disparities ...
<ul><li>De-fragmentation of Healthcare Financing  </li></ul><ul><li>and Delivery </li></ul><ul><li>Avoid fragmentation of ...
<ul><li>Strengthening Doctor-Patient Relationships: </li></ul><ul><li>–   Take measures to strengthen the stability  </li>...
<ul><li>Improve the Diversity of the Workforce: </li></ul><ul><li>Increase in the proportion of underrepresented  </li></u...
<ul><li>Patient Protections: </li></ul><ul><li>Apply the same managed care protections to publicly funded HMO enrollees th...
<ul><li>Civil Right Enforcement: </li></ul><ul><li>Provide greater resources to the U.S. DHHS Office of Civil Rights to en...
Evidence-Based Cost Control: Promote the consistency and equity of care  through the use of evidence-based guidelines     ...
<ul><li>Financial Incentives in Health Care: </li></ul><ul><li>Structure payment systems to ensure an adequate supply of s...
<ul><li>Interpretation Services: </li></ul><ul><li>Promote the use of interpretation services where community need exists ...
<ul><li>Multidisciplinary Teams: </li></ul><ul><li>Implement multidisciplinary treatment and preventive care teams that he...
Patient Education and Empowerment: Patient education programs should be implemented to increase patients’ knowledge  of ho...
DATA COLLECTION AND MONITORING: Collect and report data on health care access and utilization by patients’ race, ethnicity...
<ul><li>DATA COLLECTION AND MONITORING: </li></ul><ul><li>  </li></ul><ul><li>Monitor progress toward the elimination of h...
NEEDED RESEARCH: Conduct further research to identify sources of racial and ethnic disparities and assess promising interv...
<ul><li>Acutely aware of the value laden and sensitive nature of the subject </li></ul><ul><li>Disparities in healthcare m...
<ul><li>National dialogue </li></ul><ul><ul><li>Professional organizations </li></ul></ul><ul><ul><li>Catalyst for adding ...
<ul><li>Equity is defined as “providing care that does not vary in quality because of personal characteristics such as gen...
<ul><li>Health Care Quality </li></ul><ul><ul><li>Safety </li></ul></ul><ul><ul><li>Effectiveness </li></ul></ul><ul><ul><...
<ul><li>Severe morbidity and mortality from disease is always a tragedy. </li></ul><ul><li>Preventable morbidity and morta...
<ul><li>Immense challenges to improving our healthcare system for many populations experiencing unequal treatment. </li></...
<ul><li>Teamwork across expertise </li></ul><ul><ul><li>Building coalitions </li></ul></ul><ul><ul><li>Trusting relationsh...
The California Endowment A Partner for Healthier Communities
 
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  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • Medicare Services Study showed variation in health care utilization based on race/ethnicity for: Mammography Amputations Influenza vaccination Summary point of study: “Providing health insurance is not enough to ensure that the program is used effectively and equitably by all beneficiaries.”
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD

    1. 2. The California Endowment A Partner for Healthier Communities
    2. 3. Mobilizing to Eliminate Health Disparities 2003 Ethnic Physician Summit Carolina Reyes, MD The California Endowment
    3. 4. <ul><li>Racial/Ethnic Disparities in Health </li></ul><ul><li>The IOM Report on Racial/Ethnic Disparities in Health Care: “Unequal Treatment” </li></ul><ul><li>Major Findings and Recommendations </li></ul>Outline
    4. 5. <ul><li>Among the nation’s most serious health care problem (IOM 2002) </li></ul><ul><li>Approximately 30 percent of Americans are racial or ethnic minorities and even greater diversity of the US is expected. </li></ul><ul><li>Healthcare quality and health outcomes across ethnic and racial populations is disturbing. </li></ul>Disparities in Health Care
    5. 6. <ul><li>Despite health interventions that have improved the overall health of the majority of Americans, minorities have benefited less from these advances (NHLHI) </li></ul>Racial/Ethnic Disparities in Health
    6. 7. Cardiovascular Disease Death Rate, 1999 Deaths per 100,000 population
    7. 8. Cancer Death Rate, 1999 Deaths per 100,000 population
    8. 9. Diabetes-Related Death Rate, 1999 Deaths per 100,000 population
    9. 10. <ul><li>Social Determinants </li></ul><ul><ul><li>Education, geography, environment, housing, employment </li></ul></ul><ul><li>Access to Care </li></ul><ul><ul><li>Insurance, continuity of care </li></ul></ul><ul><li>Health Care </li></ul><ul><ul><li>Health systems and the medical encounter </li></ul></ul>What Leads to Disparities in Health?
    10. 11. <ul><li>Within Medicare: </li></ul><ul><ul><li>Differential utilization based on race for: </li></ul></ul><ul><ul><ul><li>Mammography (Gornick et al.) </li></ul></ul></ul><ul><ul><ul><li>Amputations (Gornick et al.) </li></ul></ul></ul><ul><ul><ul><li>Influenza vaccination (Gornick et al.) </li></ul></ul></ul><ul><ul><ul><li>Lung Ca Surgery (Bach et al.) </li></ul></ul></ul><ul><ul><ul><li>Renal Transplantation (Ayanian et al.) </li></ul></ul></ul><ul><ul><ul><li>Cardiac catherization & angioplasty (Harris et al, Ayanian et al.) </li></ul></ul></ul><ul><ul><ul><li>Coronary artery bypass graft (Peterson et al.) </li></ul></ul></ul><ul><ul><ul><li>Treatment of chest pain (Johnson et al.) </li></ul></ul></ul><ul><ul><ul><li>Referral to cardiology specialist care (Schulman et al.) </li></ul></ul></ul><ul><ul><ul><li>Pain management (Todd et al.) </li></ul></ul></ul>Racial/Ethnic Disparities in Health Care
    11. 12. <ul><li>Private, independent non-profit Institute of National Academy of Sciences </li></ul><ul><li>Examines issues related to health policy, health care, education and research </li></ul><ul><li>Convenes “mixed” expert panel for deliberations (6-24 months) and findings to Congress and the public </li></ul>Congressional Action: Institute of Medicine Report
    12. 13. <ul><li>Study Charge </li></ul><ul><li>Determine presence and extent of racial/ethnic disparities in health care not attributable to access </li></ul><ul><li>Evaluate potential sources of disparities including the role of bias, discrimination, and stereotyping at the individual, institutional, and health systems level </li></ul><ul><li>Provide recommendations regarding interventions to eliminate racial/ethnic disparities </li></ul>IOM’s Unequal Treatment
    13. 14. <ul><li>Eliminating disparities in health has become a national priority of the NIH, DHHS </li></ul><ul><li>Any effort to eliminate disparities will be hindered by an incomplete understanding of the social context of individuals. </li></ul>Why Study Ethnic Racial Bias?
    14. 15. <ul><li>Neglecting study of the health impact of bias, discrimination means that explanations for and interventions to alter population distributions of health, disease, and well-being will be incomplete, if not outright harmful. </li></ul>Why Study Racial Bias?
    15. 16. <ul><li>This area of work is fraught with controversy because the exposure raises important themes of accountability and human rights. </li></ul><ul><li>It is no more less germane than for research on any other social determinant. </li></ul><ul><li>It is political and unscientific to exclude this study from legitimate scientific inquiry and discourse. </li></ul>Why Study Racial Bias?
    16. 17. <ul><li>Explicitly naming a long-standing problem long recognized by those affected has the potential to galvanize or catapult inquiry and action </li></ul><ul><ul><li>“ The Battered Child Syndrome” by C. Henry Kempe </li></ul></ul><ul><ul><li>Domestic Violence </li></ul></ul>The Unnamable Is Named
    17. 18. <ul><li>Once named it becomes less nebulous and more tangible </li></ul><ul><li>Bolstered with the belief that with more rigorous documentation, analysis and resources – it could ultimately be rectified </li></ul>The Unnamable Is Named
    18. 19. Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Quality of Health Care Defining the Issues: Differences, Disparities, and Discrimination in Populations with Equal Access to Health Care Populations with Equal Access to Health Care
    19. 20. <ul><li>Sources of Data </li></ul><ul><li>Literature Search </li></ul><ul><ul><li>Over 600 papers reviewed </li></ul></ul><ul><li>Commissioned Papers </li></ul><ul><ul><li>Disparities, Legal Issues, Ethical Issues, Data Issues, etc. </li></ul></ul><ul><li>Expert Testimony </li></ul><ul><ul><li>Technical expertise and representation </li></ul></ul><ul><li>Public Workshop </li></ul><ul><ul><li>Professional and Advocacy Perspectives </li></ul></ul><ul><li>Focus Groups </li></ul><ul><ul><li>Both providers and patients </li></ul></ul><ul><li>18 Month Process </li></ul>IOM’s Unequal Treatment
    20. 21. <ul><li>Major Finding </li></ul><ul><li>Racial/Ethnic disparities consistently found across a wide range of health care settings (managed care, public/private hospitals, teaching/community, etc.), disease areas (CVD, Ca, HIV, DM, etc.) and clinical services, even when various confounders are controlled for (i.e. SES, stage of presentation, comorbidities) </li></ul>IOM’s Unequal Treatment (www.nap.edu)
    21. 22. <ul><li>Specific Findings </li></ul><ul><li>Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable. </li></ul><ul><li>They occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life. </li></ul><ul><li>Many sources – health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care. </li></ul>IOM’s Unequal Treatment (www.nap.edu)
    22. 23. <ul><li>Specific Findings </li></ul><ul><li>Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare. </li></ul><ul><li>Racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences in refusal rates are generally small, and do not fully explain healthcare disparities. </li></ul>IOM’s Unequal Treatment (www.nap.edu)
    23. 24. “ Sociocultural differences between patient and physician influence communications and clinical decision-making.” Eisenberg, 1979 Physician-Patient Communication
    24. 25. Linking Communication to Outcomes <ul><li>How do we link communication to outcomes? </li></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Patient Satisfaction </li></ul></ul><ul><ul><li>Adherence </li></ul></ul><ul><ul><li>Health Outcomes </li></ul></ul>
    25. 26. “ Medical decision-making can be as much a function of who the patient is as much as what the patient has. ” Mckinley et al., 1996 Physician Decision-Making
    26. 27. <ul><li>Focuses on questions such as: </li></ul><ul><ul><li>How do we develop perceptions and judgments of others? </li></ul></ul><ul><ul><li>What factors influence the way we form beliefs? </li></ul></ul><ul><ul><li>How do we use “social knowledge” to make decisions? </li></ul></ul>Physician Decision-Making Social Cognition
    27. 28. <ul><li>Characteristics of the Patient </li></ul><ul><ul><li>Age, Sex, SES, Race/Ethnicity, Insurance, Individual patient factors </li></ul></ul><ul><li>Characteristics of the Physician </li></ul><ul><ul><li>Specialty, Level of Training, Background </li></ul></ul><ul><li>Features of the Practice Setting </li></ul><ul><ul><li>Organization of Practice, Compensation, and expectations of productivity </li></ul></ul>Factors Affecting Physician Decision-Making
    28. 29. <ul><li>Automatic aspects; group  individual </li></ul><ul><li>“ Cognitive Misers”  cognitive shortcuts to save resources; principle of “least effort” </li></ul><ul><li>Primal->race, gender, age </li></ul><ul><li>Activated most when: </li></ul><ul><ul><li>Stressed </li></ul></ul><ul><ul><li>Under time constraints </li></ul></ul><ul><ul><li>Multitasking </li></ul></ul>Social Cognitive Theory: Stereotyping
    29. 30. <ul><li>Built on the IOM report on Crossing the Quality Chasm in 2001 </li></ul><ul><ul><li>One of the six goals to raising the overall quality of the nation’s healthcare </li></ul></ul><ul><li>Clearly stated that racial discrimination is intolerable by law </li></ul><ul><li>Contrary to the moral creed and health care ethic </li></ul>Disparities in Health Care
    30. 31. <ul><li>Arguments date back a century and a half ago </li></ul><ul><li>The task at hand is to bring the knowledge and methods available in our generation to the pressing explicit public health problem of persistent racial/ethnic health care disparities. </li></ul>Is This Inquiry New?
    31. 32. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Institute of Medicine
    32. 33. <ul><li>Insanity is when we keep doing the same thing and expecting a different result. </li></ul><ul><li>-Albert Einstein </li></ul>How Do We Begin To Address These Disparities?
    33. 34. <ul><li>Lack a robust tool bag of interventions </li></ul><ul><li>Significant disparity in the racial ethnic diversity among health professionals. </li></ul><ul><li>Language barriers are a major challenge. </li></ul>Tool Bag of Interventions
    34. 35. <ul><li>General Recommendations: </li></ul><ul><li>Increase awareness of racial and ethnic </li></ul><ul><li>disparities in health care among the general </li></ul><ul><li>public and key stakeholders </li></ul><ul><li>Increase health care providers’ awareness </li></ul><ul><li>of disparities. </li></ul><ul><li>  </li></ul>Summary of Recommendations
    35. 36. <ul><li>De-fragmentation of Healthcare Financing </li></ul><ul><li>and Delivery </li></ul><ul><li>Avoid fragmentation of health plans along </li></ul><ul><li>socioeconomic lines </li></ul>Legal, Regulatory and Policy Recommendations
    36. 37. <ul><li>Strengthening Doctor-Patient Relationships: </li></ul><ul><li>– Take measures to strengthen the stability </li></ul><ul><li>of patient-provider relationships in publicly </li></ul><ul><li>funded health plans </li></ul>Legal, Regulatory and Policy Recommendations
    37. 38. <ul><li>Improve the Diversity of the Workforce: </li></ul><ul><li>Increase in the proportion of underrepresented </li></ul><ul><li>U.S. racial and ethnic minorities among health professionals; </li></ul>Legal, Regulatory and Policy Recommendations
    38. 39. <ul><li>Patient Protections: </li></ul><ul><li>Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees </li></ul>Legal, Regulatory and Policy Recommendations
    39. 40. <ul><li>Civil Right Enforcement: </li></ul><ul><li>Provide greater resources to the U.S. DHHS Office of Civil Rights to enforce civil rights laws. </li></ul>Legal, Regulatory and Policy Recommendations
    40. 41. Evidence-Based Cost Control: Promote the consistency and equity of care through the use of evidence-based guidelines     Health Systems Interventions
    41. 42. <ul><li>Financial Incentives in Health Care: </li></ul><ul><li>Structure payment systems to ensure an adequate supply of services to minority patients, and limit provider incentives that may promote disparities; </li></ul><ul><li>Provide financial incentives for practices that Enhance patient-provider communication Encourage evidence-based practice </li></ul>Health Systems Interventions
    42. 43. <ul><li>Interpretation Services: </li></ul><ul><li>Promote the use of interpretation services where community need exists </li></ul><ul><li>Community Health Workers </li></ul><ul><li>Support the use of community health workers </li></ul>Health Systems Interventions
    43. 44. <ul><li>Multidisciplinary Teams: </li></ul><ul><li>Implement multidisciplinary treatment and preventive care teams that help coordinate and streamline care </li></ul>Health Systems Interventions
    44. 45. Patient Education and Empowerment: Patient education programs should be implemented to increase patients’ knowledge of how to best access care and participate in treatment decisions. Cross-Cultural Education in Health Professions:   Integrate cross-cultural education into the training of all current and future health professionals. Health Systems Interventions
    45. 46. DATA COLLECTION AND MONITORING: Collect and report data on health care access and utilization by patients’ race, ethnicity, socio-economic status, and where possible, primary language; Include measures of racial and ethnic disparities in performance measurement;   Health Systems Interventions
    46. 47. <ul><li>DATA COLLECTION AND MONITORING: </li></ul><ul><li>  </li></ul><ul><li>Monitor progress toward the elimination of health care disparities; </li></ul><ul><li>Report racial and ethnic data by OMB categories, but use subpopulation groups where possible </li></ul>Health Systems Interventions
    47. 48. NEEDED RESEARCH: Conduct further research to identify sources of racial and ethnic disparities and assess promising intervention strategies, and;   Conduct research on ethical issues and address barriers to research of disparities in care Health Systems Interventions
    48. 49. <ul><li>Acutely aware of the value laden and sensitive nature of the subject </li></ul><ul><li>Disparities in healthcare may be reflective of inequalities in other aspects of American life </li></ul><ul><li>The real challenge is embracing and acting on these recommendations </li></ul><ul><li>Requires a broad and sustained commitment from all of us </li></ul>Conclusions
    49. 50. <ul><li>National dialogue </li></ul><ul><ul><li>Professional organizations </li></ul></ul><ul><ul><li>Catalyst for adding cultural competency under the rubric of quality care </li></ul></ul><ul><ul><li>Health plans are developing strategies to address race/ethnicity disparities </li></ul></ul>What has been the Impact of the IOM report to date?
    50. 51. <ul><li>Equity is defined as “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status” </li></ul><ul><li>For populations, equity means reducing disparities in the use of health care services that are related to personal characteristics </li></ul>Guiding the National Healthcare Disparities Report
    51. 52. <ul><li>Health Care Quality </li></ul><ul><ul><li>Safety </li></ul></ul><ul><ul><li>Effectiveness </li></ul></ul><ul><ul><li>Patient Centeredness </li></ul></ul><ul><ul><li>Timeliness </li></ul></ul>Guiding the National Healthcare Disparities Report
    52. 53. <ul><li>Severe morbidity and mortality from disease is always a tragedy. </li></ul><ul><li>Preventable morbidity and mortality is unjust. </li></ul>Guiding the National Healthcare Disparities Report
    53. 54. <ul><li>Immense challenges to improving our healthcare system for many populations experiencing unequal treatment. </li></ul><ul><li>Immense commitment </li></ul><ul><ul><li>Strategize with colleagues </li></ul></ul><ul><ul><li>Create new partnerships </li></ul></ul><ul><ul><li>Explore our own role towards elimination of disparities </li></ul></ul>Conclusion
    54. 55. <ul><li>Teamwork across expertise </li></ul><ul><ul><li>Building coalitions </li></ul></ul><ul><ul><li>Trusting relationships </li></ul></ul><ul><li>Tenacity </li></ul><ul><li>Realistic </li></ul><ul><li>Hopeful </li></ul><ul><li>Keep our attention focused on the possible </li></ul>Sustained Policy Change
    55. 56. The California Endowment A Partner for Healthier Communities

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