When starting in a new ACO, understanding health equity and how it impacts your outcomes as well as your benchmark is essential. While ACO REACH has the requirement of health equity plans for what areas the ACO is planning to impact, MSSP ACOs also have health equity incentives with an optional advanced payment specifically for infrastructure investments needed to care for patients with higher needs such as dual eligible patients and patients who show deprivation according to the Area Deprivation Index (ADI). The MSSP model also has a health equity adjustment that provides bonus points on the MIPS quality performance for high performance addressing specific health equity and Social Determinants (or drivers) of Health (SDOH) challenges. Doing outreach to underserved communities and caring for them in a culturally appropriate manner can significantly adjust your benchmarks and incentivize the care of high needs population.
What Is Health Equity?
CMS defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes.” This is a broad statement which requires more details to be able to fully move toward a health equity focus. Often, it is confusing to understand the difference between health equity and SDOH. SDOH are factors that may impede (or enhance) access to fully equitable healthcare – so, a factor impacting health equity. But before data collection on your patient population begins, organizations must understand the organizational culture and needs on Diversity Equity and Inclusion (DEI).
DEI Work for ACOs
In starting DEI work, it is best to start with internal audits of the makeup of your team from board of directors to volunteers and identify if it matches your population. Studies have shown that patients from minority cultures feel most comfortable with people who speak their language and understand their culture. If this is not available, having people involved in their care who have some understanding and training in the specific needs and language does make many of the people more comfortable. Culturally and Linguistically Appropriate Services (CLAS) is a way to provide care that is respectful and responsive to health beliefs, practice, and needs of a diverse group of patients. CLAS training will help your team with both knowing how to ask sensitive questions about gender identity, sexual/romantic orientation, race, and ethnicity in a manner that patients who have been conditioned to not share this data for fear of discrimination as well as understanding how social drivers of health, ethnicity, and sexual orientation/gender identity can impact health outcomes. Review hiring and training policies to ensure that health equity is a priority in both.
Non-Medical Health Related Social Needs (HRSN)
Understanding the needs of your community and making connections to meet those needs, especially non-medical needs (transportation, food, water) is the next step in health equity. Use of the ADI, which is based on census data, is essential to understanding your population’s health related social needs (HRSN) as well as looking at published census data on the racial and ethnic makeup of your service area. A client recently told me that they want to make inroads to the Black community by doing heart health screenings in primarily Black communities since Black people statistically have higher rates of hypertension. However, when reviewing the ADI of the service area, the non-medical needs of these areas showed potential food and nutrition insecurity as well as transportation gaps. While screening for the presence of unmet hypertensive disease and potential sequalae is an important medical need of the Black population, not having adequate and/or nutritional food will make the work done for hypertension care less effective. Understanding the ADI will allow targeted interventions that impact the right measures. Partnering with community-based organizations (CBO) to meet the non-medical needs of your population is essential to addressing these identified needs.
Prioritizing an SDOH Assessment
CMS is making the collection and reporting of advanced demographics and SDOH data a priority. Use of standardized assessments (two of which are inside of the Acclivity platform) enables data to be collected and aggregated in a consistent measure for future use. However, ensure there is more than one way to collect this information. The CMS Framework for Health Equity 2022-2032 states that while the increased use of technology can assist with collection of SDOH and demographics information, underserved communities have higher rates of cut-off or suspended smart-phone service, and some rural communities do not have access to broadband internet. Be flexible in the manner of collecting this data – use of in office questionnaires that are read to the patient, or the patient can read themselves (note that literacy may not be at a high enough level to have all people able to answer a questionnaire), patient portals, and use of the primary language of the patient can increase the collection of this vital data. Training the team on how to ask these questions in a culturally sensitive manner is essential as many members of marginalized communities may be guarded in their responses to some questions. Once one of the approved SDOH assessments has been completed, it is essential to assign an ICD-10 Z code that identifies the need. CMS updates the list of SDOH associated Z codes twice yearly and continues to add more specific codes to identify these needs on the patient chart for ease in care planning the needs and tracking outcomes.
CMS has long term plans on use of the SDOH and advanced demographics information to identify trends and outcomes as well as develop new programs and funding opportunities to assist with the ultimate goal of health equity. Starting with accurate data collection is key to having the correct actionable data. However, to ensure we are collecting data accurately and have the ability to provide care to the underserved communities in your service area, starting with a DEI initiative to ensure all are able to provide culturally appropriate care and assessments and you have a team that understands and feels competent to provide care for the population in your service area is an essential first step to all health equity measures.
Learn More About Health Equity and SDOH
Visit the Acclivity SDOH page for more information on matters relating to Health Equity and SDOH.
Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions