HPHCInitiatives forCulturally and Linguistically Appropriate Services –2011 Update

Introduction

Harvard Pilgrim Health Care has been monitoring the quality of care its members receive for over thirty years. Racial/ethnic disparities in care were first identified among HPHC members in 2002, through a health assessment partnership with the Massachusetts Department of Public Health. Also in 2002, the Institute of Medicine published Unequal Treatment, a report summarizing the research evidence regarding racial/ethnic disparities in care and outlining recommendations to reduce them. The IOM report, combined with Harvard Pilgrim data from the health assessment partnership helped to make the business case for an initiative to identify and reduce disparities among our members. In 2004, Harvard Pilgrim became one of the initial ten members of the National Health Plan Collaborative to Reduce Racial and Ethnic Disparities in Care. In 2005, Harvard Pilgrim formally incorporated disparities initiatives into its annual quality work plan and performance metrics. After consultation with the Harvard Pilgrim Ethics Advisory Group it was decided that our disparities initiative should focus on disparities related to gender, education, income and health status as well as racial/ethnic disparities.

Since then, Harvard Pilgrim has focused on developing and producing an annual equity report to theHarvard Pilgrim Medical Management and Quality Committee on the status of efforts to identify and reduce disparities in health care and customer service and to enhance the provision of culturally and linguistically appropriate services for members. This report is also presented to the Patient Care Assessment Committee of the Harvard Pilgrim Board of Directors and highlights are shared with the full Board.

Harvard Pilgrim has implemented both global and targeted strategies to:

  • collect self-reported race, ethnicity and language (REL) for its members;
  • apply tools to geo/surname code and indirectly estimate race and ethnicitydesignations for members for whom self-reported race and ethnicity data are unavailable;
  • use both self-reported and indirectly estimated REL data to analyze Harvard Pilgrim’s performance on both clinical quality and service metrics and identify any disparities;
  • use REL data to target provider groups and communities for interventions to reduce identified disparities;
  • use REL data to target member materials for translation;
  • use REL data to assure the availability of interpreter services;
  • use REL data to incorporate culturally appropriate messaging into outreach and education materials;
  • implement member, provider and community-based interventions to reduce identified disparities in care; and
  • evaluate the effectiveness of the disparities reduction efforts.

Through the National Health Plan Collaborative, Harvard Pilgrim learned to use analytic tools based on geocoding and surname coding to identify racial and ethnic disparities in patient care and has applied these tools to analyze performance on twenty-six clinical quality indicators, as well as measures of members’ experiences with their clinical care providers and with Harvard Pilgrim’s customer service functions. These tools allow HPHC to identify disparities at a population level and to target interventions to communities and provider groups. However, these tools are more limited in their capacity to identify the racial/ethnic background of individual members who may not be receiving clinically recommended care or services. Ideally, self-reported data are needed to deliver targeted, culturally appropriate interventions directly to individual members. In 2007, Harvard Pilgrim launched an aggressive initiative to increase the collection of self-reported race, ethnicity and language data from members and to incorporate these data into our enterprise data warehouse to support disparities analysis, reporting and outreach efforts.

Efforts to Identify and Reduce Disparities in Care

The following are some of Harvard Pilgrim’s initiatives to reduce health care disparities.

Global Strategies to Identify and Reduce Disparities

  • Provide culturally and linguistically appropriate services
  • Provide both cultural competency training and medical interpreter training through the Harvard Pilgrim Health Care Foundation’s Culture InSight program
  • Provide interpreter services for members calling Harvard Pilgrim’s Member Services and/or clinical departments
  • Provide information in the Harvard Pilgrim Provider Directory on languages spoken in practitioner offices
  • Provide subscriber materials and patient education materials in multiple languages
  • Incorporate culturally appropriate messages into member outreach initiatives
  • Implement a routine monitoring system to identify disparities in quality of care and service
  • Analyze CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey data on member experiences with Harvard Pilgrim and its practitioner network by race/ethnicity to identify any disparities in access to needed care, provider communication and/or member services
  • Measure performance on 26HEDIS (Healthcare Effectiveness Data and Information Set) clinical quality and access measures stratified by race/ethnicity and identify any potential disparities in quality of care
  • Identify other factors (e.g., gender, income, education, geography, usual source of care, benefit package) that may contribute to identified disparities
  • Report annually to the Medical Management and Quality Committee on any identified disparities and recommend interventions to address gaps in care
  • Design interventions to address as many factors contributing to identified disparities as possible, and evaluate their effectiveness in improving care and reducing disparities
  • Provide ongoing education and training of Harvard Pilgrim Nurse Care Managersfocusing on the need to address cultural and linguistic issues in order to positively affect member care plans. Training and education activities include:
  • Participation in “Working with Differences” training
  • Required attendance at weekly clinical case conferences that include cultural and linguistic issues in case presentations
  • Use of Language Interpreter Servicesto better identify member needs
  • Use of motivational interviewing techniquesthat include individual coaching and suggested approaches to achieve culturally competent communication
  • Use of documentation standards that address cultural and linguistic issues
  • Incorporation of training specific to cultural issues in the new Care Management programs (Oncology and Pregnancy)with specific modules addressing cultural issues
  • Training programs, organized by the Care Management department and open to HPHC licensed staff, that include cultural and linguistic issues in:
  • Pain Management,related tomedication adherence, and the need for diversity in clinical trials and studies of bioavailability of medication
  • Cardiac findings from the Nurses Health Study
  • Domestic Violence training
  • Provide subsidized Medical Interpreter and Cultural Competency training programs to several local provider organizations through the HPHC Foundation’s Culture InSight program
  • Conduct a Health Literacy Organizational Assessment and implement training programs and other targeted initiatives to improve the health literacy of member communications and educational materials

Targeted Disparities and Interventions

  • Well Infant Visits
  • Identified disparity in completion of 6 well baby visits by age 15 months among black and Hispanic members
  • Published article on the importance of visits for preventive care in member newsletter
  • Became sponsor of Text4Baby, a national initiative that provides free text messaging to promote healthy pregnancy and infant care; provided bilingual member outreach to promote the service to new moms; worked with our Nurse Care Managers to promote the service to members in our high risk pregnancy program.
  • Well Adolescent Visits
  • Identified disparity in completion of an annual well adolescent visit among black and Hispanic members
  • Found that most adolescents had at least one primary care visit in past 12 months but not necessarily a preventive care visit; published article in provider newsletter on providing well care during other visit types and proper documentation of well visits
  • Implemented a member incentive program to encourage well adolescent visits and targeted the incentive to those at highest risk of failing to receive a well visit (black and Hispanic adolescents, older adolescents and those living in neighborhoods with lower income and education levels).
  • Creating a new webpage for teens with a variety of healthy messages and links to teen-friendly websites that promote healthy behaviors
  • Colorectal Cancer (CRC) Screening
  • Targeted disparity: a lower CRC screening rate among Hispanic/Latino members
  • From 2006 through 2008, outreach calls using interactive voice response (IVR) technology were made to members who had not been adequately screened for CRC based on claims analysis. In addition to educational messages provided through IVR, members were offered additional written materials in Spanish, as well as English, and subsequently the entire call was offered in Spanish. This intervention received a 2007 Innovation in Multicultural Health Care Award from the National Committee for Quality Assurance.
  • Beginning in 2009, targeted bilingual mailings and educational materials are sent to members who have not been screened.
  • Asthma medications
  • Reviewed, updated and enhanced all existing patient education materials
  • Increased availability of educational materials in Spanish and other languages
  • Lowered the reading level to improve health literacy
  • Implemented interactive voice response (IVR) campaigns on asthma which include offering adult and pediatric versions of theAsthma Action Plan to members in other languages (e.g., Spanish, Portuguese, Russian, Vietnamese, Chinese, Haitian Creole, and Khmer)
  • Educational mailings include several bilingual (English/Spanish) pieces and also reference availability of the Asthma Action Plan in other languages
  • Beta Blocker
  • Mailed Taking A Beta-Blocker for Life brochure in English and Spanish
  • Retinal Screening among members with Diabetes
  • Targeted disparity: lower retinal screening rate among Hispanic/Latino members
  • Removed the referral requirement for diabetic retinal screening exams
  • Lowered reading levels to improve health literacy and translated educational materials into Spanish and Portuguese

Initiatives to Collect Member Race, Ethnicity and Language Preferences

Over the past four years, Harvard Pilgrim has expanded and accelerated its efforts to collect self-reported race, ethnicity and language (REL) data for its members. This expansion has been undertaken in response to:

(1)Pervasive evidence that racial and ethnic disparities exist in the nation’s health care system, even among those with comprehensive health insurance coverage.

(2)Increasing evidence that racial and ethnic disparities exist among provider organizations.

  1. Some disparities are related to people getting care from lower-performing physician groups, hospitals, or other care providers
  2. Some disparities occur across and within individual physician practices in high-performing groups.

(3)Evidence that disparities in care exist among Harvard Pilgrim members.

(4)The need to target and culturally tailor quality improvement interventions to reduce disparities in care among Harvard Pilgrim members.

(5)Recent state mandates to collect and report race and ethnicity data and, in Massachusetts, language data as well.

How is Harvard Pilgrim currently collecting REL data?

(1)Subscribers who self enroll online via HPHConnect have an opportunity to provide race/ethnicity and language data voluntarily. However, such race/ethnicity data were not fed into HPHC’s core enrollment system, because the system had no field in which to store the information. Harvard Pilgrim accessed existing data directly from HPHConnect database for the first time in July 2008. Ongoing feeds to the Enterprise Data Warehouse (EDW) from HPHConnect began in July 2009.

(2)A pilot project asking members to share their race and ethnicity with Harvard Pilgrim in the context of a preventive care outreach call using IVR technology was conducted in June 2007. Approximately 95% of members who were asked about their race/ethnicity provided their information, and no negative comments were received. Expansion of the race/ethnicity questions to additional IVR outreach efforts (e.g., flu shot reminders, adult asthma care) began in 2008 and periodic data feeds to the EDW were implemented in July 2009.

(3)A modification to HPHC’s medical records documentation standards to recommend the documentation of patients’ self-reported race/ethnicity in providers’medical records was implemented in December2007. An audit of compliance was performed in December 2008 and revealed that compliance was highly variable by practice and generally low. In 2009, articles were published in member and provider newsletters stressing the value of including patients’race, ethnicity and language in medical record documentation.

(4)Beginning in November 2008, a pop-up survey appears when members who have not yet reported their race, ethnicity or language sign on to the HPHConnect secure member portal. Data collected via this survey were first fed into the EDW in July 2009. Strategies to encourage more members to sign up for an HPHConnect account are underway and should result in more surveys being completed.

(5)A new online Health Risk Appraisal (HRA) was implemented in July 2008 and includes questions about the user’s race/ethnicity. Monthly feeds from the HRA files to the EDW began in October 2010.

(6)A new care management system was implemented in 2010 and now enables nurse care managers and disease management nurses to enter self-reported data on members’ race, ethnicity and language in their care management record. Electronic feeds to and from the new care management system and EDW are planned for early 2011.

(7)Massachusetts mandated the collection of race and ethnicity by all hospitals in the state, effective January 1, 2007. In early 2009, Harvard Pilgrim began requesting that hospitals and medical groups share the race, ethnicity and language data they have collected from Harvard Pilgrim members. Two hospitals that serve large percentages of HPHC members, and the largest medical group,have beensharing members’ REL dataon a quarterly basis since 2009. Two additional hospitals began reporting REL data in the summer of 2010. Electronic data feeds to the EDW from hospital and medical group reporting files were implemented in July 2009.

Future expansion opportunities under consideration include:

(1)New medical home pilots incorporate the measurement of meaningful use of electronic health records, including documentation of patients’ race, ethnicity and language; sharing of REL data with health plans could be encouraged through medical home and/or EHR incentive programs.

(2)Postcard or telephonic surveys may be implemented in 2010 in conjunction with standard member communications (e.g.,member newsletter article, new ID card mailer).

(3)Modifications of paper enrollment forms and/or sharing of data by large employers may be pursued in 2011.

How are the data being protected?

Harvard Pilgrim has adopted a policy of treating race, ethnicity and language data as Personal Health Information (PHI), affording all of the protections given to PHI under the HIPAA Privacy Rule. REL data at the individual member level will only be accessible through the EDW. An internal policy document outlining HPHC’s data confidentiality and security policy for REL data was adopted in December 2008, prior to making any REL data available for analysis in the EDW. Initially, these data will only be available to staff in Harvard Pilgrim’s Health Services department who are working on disparities monitoring and reduction initiatives, and to staff in Corporate Information Management who prepare the file extract submissions mandated by the Massachusetts Health Care Quality and Cost Council. Other business units that have a need for these data to address disparities may submit a request to HPHC’s Chief Medical Officer, Chief Information Officer and Privacy Officer.

Please refer to the accompanying slide presentation for additional details on the process used to create our annual equity report.

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