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Achieving Health Equity in Care Settings

Healthy People 2020 proposes, “to achieve health equity, eliminate disparities, and improve the health of all groups” and defines health equity as the “attainment of the highest level of health for all people.  Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.

Behavioral health inequities are pervasive in diverse communities; people are less likely to be diagnosed with mental illness, have access to, or receive high quality care.  Healthy People 2020 defines Social Determinants of Health (SDOH) as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH like culture, neighborhood, socio-economic status, language and more, impact the health of individuals and populations, where marginalized populations often experience worse health outcomes than non-marginalized populations.

How can clinic staff educate themselves to best address social determinants of health to make health equity a reality for diverse populations?

Achieving health equity in clinics is a three-pronged approach:

1.     Community Engagement

2.     Amplifying the voices of marginalized populations

3.     Educating providers and frontline staff on biases and stigma

High-quality care cannot be provided by a clinic unless clients seek care there. Often people in marginalized communities distrust the healthcare system. Therefore, creating a welcoming environment is essential. To achieve health equity, clinic staff must engage with the communities and populations they want to serve. Clinics can advertise their services in local community settings, like churches, community centers, food pantries, libraries or schools, to inform community members of available services using the community spaces they trust. Adapting marketing and clinic materials as well as hiring staff to reflect the cultural and linguistic preferences of marginalized populations can also make the clinic more accessible and welcoming.

When marginalized populations use services at the clinic, it is essential to listen to and remember their stories and needs without making assumptions about or tokenizing their experiences. Additionally, it is essential that clinic staff acknowledge the heterogeneity across and within specific racial and ethnic populations.  Offering clients positions on a peer advisory board can help improve the accessibility of the clinic and as well as the tailoring of services.

Top resources for considering social determinants of health to eliminate health disparities

The connection between social determinants of health and health equity is complicated, especially in terms of their impact on health outcomes.  Check out the National Academy of Medicine’s newest report, Perspectives on Health Equity & Social Determinants of Health (https://nam.edu/wp-content/uploads/2017/12/Perspectives-on-Health-Equity-and-Social-Determinants-of-Health.pdf) to begin unpacking these concepts and understand how they apply in your clinical setting. 

Community engagement starts with understanding the needs of diverse populations and catering services to match their needs.  The Inclusive Outreach and Public Engagement Guide (https://www.seattle.gov/Documents/Departments/RSJI/GRE/IOPEguide01-11-12.pdf) provides six essential strategies to set the framework for outreach efforts.  Once engaged, starting the conversation with communities may be challenging. Check out SAMHSA’s Community Conversations About Mental Health Toolkit (https://www.samhsa.gov/community-conversations) for discussion guides and information briefs. 

As an organization, review the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf) and the CLAS Blueprint (https://www.thinkculturalhealth.hhs.gov/clas/blueprint) to ensure that there is organization-wide priority to address social determinants of health. 

Hearing stories from clients can provide insight on how to meet them where they are and begin addressing holistic care needs.  Check out the Visualize Health Equity Project (http://nam.edu/visualizehealthequity/#/) to see ways people envision health equity in their communities. Their art provides a unique entry point to understanding the challenges these populations face and amplifies their point of view through a different medium. 

Find additional resources through SAMHSA’s Office of Behavioral Health Equity (https://www.samhsa.gov/behavioral-health-equity) for the following populations of focus:

·       Asian American, Native Hawaiian, and Pacific Islander (https://www.samhsa.gov/behavioral-health-equity/aanhpi)

o   Statistics: https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=54

·       American Indian and Alaska Native: Tribal Affairs (https://www.samhsa.gov/behavioral-health-equity/ai-an)

o   Statistics (https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=39)

·       Black or African American (https://www.samhsa.gov/behavioral-health-equity/black-african-american)

o   Statistics (https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24)

·       Hispanic or Latino (https://www.samhsa.gov/behavioral-health-equity/hispanic-latino)  

o   Statistics (https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=69)

·       Lesbian, Gay, Bisexual, and Transgender (LGBT) (https://www.samhsa.gov/behavioral-health-equity/lgbt) 

Though not an exhaustive list, these resources can start the conversation on how to adapt materials to better suit the cultural and linguistic needs of diverse populations and welcome clients.  Encourage clinicians to improve their cross-communication through the use of the LEARN Model (https://pages.shanti.virginia.edu/fmchallpatient/files/2011/12/Refugee.PGY1_.LEARN-Model.pdf).

Eliminating health disparities for diverse populations starts with increasing accessibility to care, amplifying their needs, and educating providers to consider additional culturally specific factors during care. The National Network to Eliminate Disparities in Behavioral Health (http://nned.net/) encourages collective information sharing among a national network of providers dedicated to this work; tune in to their work to learn more about how other providers are incorporating addressing health disparities in their daily practices. 

Once culturally and linguistically sensitive practices have been incorporated into practices, it is essential to measure any impact they have on health outcomes for populations of focus. The Using Social Determinants of Health Data to Improve Health Care and Health: A Report (https://www.rwjf.org/content/dam/farm/reports/reports/2016/rwjf428872), showcases high impact case studies at different levels of healthcare. 

For more resources, check out the SAMHSA-HRSA Center for Integrated Health Solutions website: https://www.integration.samhsa.gov/clinical_practice/healthdisparities

Case Study: Citrus Health Network, Inc. 

Walking into the Citrus Health Network, a health center located in Florida, I was greeted by a friendly smile and “Hola” behind the front desk. Looking around, I saw posters, flyers, and forms are all available in English and Spanish. I was impressed; it looked like this organization knew how to cater to a Spanish-speaking population. As I chatted with Marta Pizarro, Program Developer/PBHCI Project Director at Citrus, I quickly realized that the few things I noticed were only the tip of the iceberg. Citrus has adapted their materials and services to better serve diverse populations as it aims to achieve health equity.

Marta said that translating materials into Spanish is only a start. The clinic serves Cubans, Puerto Ricans, and clients from various Central and South American countries, with significant variations in terms and expressions among these Spanish speaking groups.  The clinic also serves Haitian-Creole clients. Each of these groups has a unique culture and set of values. Most national resources translated into Spanish cater to the Mexican population; Citrus has made it a priority to modify these resources to meet the unique cultural and language characteristics of the main populations served, such as changing the nutrition flyer to include Cuban foods.

Additionally, many clients are immigrants and struggle to adapt to and navigate the complex American healthcare system. Numerous clients come from countries that do not have enough resources to provide excellent healthcare or offer preventative services. To address some of these concerns, the staff take extra care to approach clients about primary care services and the benefits. Many members of the staff are immigrants or come from immigrant backgrounds and can explain the healthcare system from a point of view that resonates with the clients.

Representation matters, and having cultural values reflected in the staff and the clinic’s services helps clients engage and feel more comfortable in the setting. Staff meet clients where they are, considering ways they can encourage clients to take advantage of the services in the system. However, staff also acknowledge that people coming for psychiatric services may not access primary care services due to the financial burden, as there may be other social determinants of health, like housing and food, that need to be addressed first for these individuals.  To address this challenge, Citrus has a network to help  staff bridge the gap in the continuum of care and connect clients to housing and other social services.

On a systems level, numerous immigrants from Spanish-speaking regions sit on an advisory board.  The advisory board advocates to consider different approaches to address challenges encountered rather than discontinuing primary care or other services for clients.

Citrus continues their efforts to achieve health equity by providing continuous cultural and linguistic training for their staff. Additionally, they have hired the YES Institute to evaluate all of their forms and ensure there is no re-traumatization by the form language. The Citrus team continues to be responsive to the needs of their diverse community and is a great example of steps to take to welcome marginalized populations into clinics.

Call Our Helpline: 202.684.7457

Healthy People 2020 proposes, “to achieve health equity, eliminate disparities, and improve the health of all groups” and defines health equity as the “attainment of the highest level of health for all people.  Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.

Behavioral health inequities are pervasive in diverse communities; people are less likely to be diagnosed with mental illness, have access to, or receive high quality care.  Healthy People 2020 defines Social Determinants of Health (SDOH) as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH like culture, neighborhood, socio-economic status, language and more, impact the health of individuals and populations, where marginalized populations often experience worse health outcomes than non-marginalized populations.

How can clinic staff educate themselves to best address social determinants of health to make health equity a reality for diverse populations?

Achieving health equity in clinics is a three-pronged approach:

1.     Community Engagement

2.     Amplifying the voices of marginalized populations

3.     Educating providers and frontline staff on biases and stigma

High-quality care cannot be provided by a clinic unless clients seek care there. Often people in marginalized communities distrust the healthcare system. Therefore, creating a welcoming environment is essential. To achieve health equity, clinic staff must engage with the communities and populations they want to serve. Clinics can advertise their services in local community settings, like churches, community centers, food pantries, libraries or schools, to inform community members of available services using the community spaces they trust. Adapting marketing and clinic materials as well as hiring staff to reflect the cultural and linguistic preferences of marginalized populations can also make the clinic more accessible and welcoming.

When marginalized populations use services at the clinic, it is essential to listen to and remember their stories and needs without making assumptions about or tokenizing their experiences. Additionally, it is essential that clinic staff acknowledge the heterogeneity across and within specific racial and ethnic populations.  Offering clients positions on a peer advisory board can help improve the accessibility of the clinic and as well as the tailoring of services.

Top resources for considering social determinants of health to eliminate health disparities

The connection between social determinants of health and health equity is complicated, especially in terms of their impact on health outcomes.  Check out the National Academy of Medicine’s newest report, Perspectives on Health Equity & Social Determinants of Health (https://nam.edu/wp-content/uploads/2017/12/Perspectives-on-Health-Equity-and-Social-Determinants-of-Health.pdf) to begin unpacking these concepts and understand how they apply in your clinical setting. 

Community engagement starts with understanding the needs of diverse populations and catering services to match their needs.  The Inclusive Outreach and Public Engagement Guide (https://www.seattle.gov/Documents/Departments/RSJI/GRE/IOPEguide01-11-12.pdf) provides six essential strategies to set the framework for outreach efforts.  Once engaged, starting the conversation with communities may be challenging. Check out SAMHSA’s Community Conversations About Mental Health Toolkit (https://www.samhsa.gov/community-conversations) for discussion guides and information briefs. 

As an organization, review the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf) and the CLAS Blueprint (https://www.thinkculturalhealth.hhs.gov/clas/blueprint) to ensure that there is organization-wide priority to address social determinants of health. 

Hearing stories from clients can provide insight on how to meet them where they are and begin addressing holistic care needs.  Check out the Visualize Health Equity Project (http://nam.edu/visualizehealthequity/#/) to see ways people envision health equity in their communities. Their art provides a unique entry point to understanding the challenges these populations face and amplifies their point of view through a different medium. 

Find additional resources through SAMHSA’s Office of Behavioral Health Equity (https://www.samhsa.gov/behavioral-health-equity) for the following populations of focus:

·       Asian American, Native Hawaiian, and Pacific Islander (https://www.samhsa.gov/behavioral-health-equity/aanhpi)

o   Statistics: https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=54

·       American Indian and Alaska Native: Tribal Affairs (https://www.samhsa.gov/behavioral-health-equity/ai-an)

o   Statistics (https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=39)

·       Black or African American (https://www.samhsa.gov/behavioral-health-equity/black-african-american)

o   Statistics (https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24)

·       Hispanic or Latino (https://www.samhsa.gov/behavioral-health-equity/hispanic-latino)  

o   Statistics (https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=69)

·       Lesbian, Gay, Bisexual, and Transgender (LGBT) (https://www.samhsa.gov/behavioral-health-equity/lgbt) 

Though not an exhaustive list, these resources can start the conversation on how to adapt materials to better suit the cultural and linguistic needs of diverse populations and welcome clients.  Encourage clinicians to improve their cross-communication through the use of the LEARN Model (https://pages.shanti.virginia.edu/fmchallpatient/files/2011/12/Refugee.PGY1_.LEARN-Model.pdf).

Eliminating health disparities for diverse populations starts with increasing accessibility to care, amplifying their needs, and educating providers to consider additional culturally specific factors during care. The National Network to Eliminate Disparities in Behavioral Health (http://nned.net/) encourages collective information sharing among a national network of providers dedicated to this work; tune in to their work to learn more about how other providers are incorporating addressing health disparities in their daily practices. 

Once culturally and linguistically sensitive practices have been incorporated into practices, it is essential to measure any impact they have on health outcomes for populations of focus. The Using Social Determinants of Health Data to Improve Health Care and Health: A Report (https://www.rwjf.org/content/dam/farm/reports/reports/2016/rwjf428872), showcases high impact case studies at different levels of healthcare. 

For more resources, check out the SAMHSA-HRSA Center for Integrated Health Solutions website: https://www.integration.samhsa.gov/clinical_practice/healthdisparities

Case Study: Citrus Health Network, Inc. 

Walking into the Citrus Health Network, a health center located in Florida, I was greeted by a friendly smile and “Hola” behind the front desk. Looking around, I saw posters, flyers, and forms are all available in English and Spanish. I was impressed; it looked like this organization knew how to cater to a Spanish-speaking population. As I chatted with Marta Pizarro, Program Developer/PBHCI Project Director at Citrus, I quickly realized that the few things I noticed were only the tip of the iceberg. Citrus has adapted their materials and services to better serve diverse populations as it aims to achieve health equity.

Marta said that translating materials into Spanish is only a start. The clinic serves Cubans, Puerto Ricans, and clients from various Central and South American countries, with significant variations in terms and expressions among these Spanish speaking groups.  The clinic also serves Haitian-Creole clients. Each of these groups has a unique culture and set of values. Most national resources translated into Spanish cater to the Mexican population; Citrus has made it a priority to modify these resources to meet the unique cultural and language characteristics of the main populations served, such as changing the nutrition flyer to include Cuban foods.

Additionally, many clients are immigrants and struggle to adapt to and navigate the complex American healthcare system. Numerous clients come from countries that do not have enough resources to provide excellent healthcare or offer preventative services. To address some of these concerns, the staff take extra care to approach clients about primary care services and the benefits. Many members of the staff are immigrants or come from immigrant backgrounds and can explain the healthcare system from a point of view that resonates with the clients.

Representation matters, and having cultural values reflected in the staff and the clinic’s services helps clients engage and feel more comfortable in the setting. Staff meet clients where they are, considering ways they can encourage clients to take advantage of the services in the system. However, staff also acknowledge that people coming for psychiatric services may not access primary care services due to the financial burden, as there may be other social determinants of health, like housing and food, that need to be addressed first for these individuals.  To address this challenge, Citrus has a network to help  staff bridge the gap in the continuum of care and connect clients to housing and other social services.

On a systems level, numerous immigrants from Spanish-speaking regions sit on an advisory board.  The advisory board advocates to consider different approaches to address challenges encountered rather than discontinuing primary care or other services for clients.

Citrus continues their efforts to achieve health equity by providing continuous cultural and linguistic training for their staff. Additionally, they have hired the YES Institute to evaluate all of their forms and ensure there is no re-traumatization by the form language. The Citrus team continues to be responsive to the needs of their diverse community and is a great example of steps to take to welcome marginalized populations into clinics.

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