3 Steps to Addressing Socioeconomic Barriers to Achieve Better Outcomes

Meet Sonia: she’s an 86-year-old woman born in Poland, who has outlived her husband, suffers from depression and diabetes and has just been discharged from hospital following surgery. She’s unable to afford the medication prescribed to her and has few family members or friends around to help her safely travel to a neighbourhood clinic and receive the proper follow-up care.

Sonia represents the dilemma many Ontario seniors will face in the coming years. We know that by 2030, 70 per cent of Ontario seniors will be living with two or more chronic conditions, similar to Sonia. What we don’t know is how many seniors like Sonia are being disadvantaged because of their socioeconomic living conditions. The fact that she has trouble communicating in English, that she has a small support network, and that she lives on a small income means she’s more likely to experience poorer health outcomes than individuals without these types of variables.

I believe that too few health organizations consider the added dimension of socioeconomic living conditions. Under tremendous pressures, teams work diligently to treat episodes of illness but often neglect important socioeconomic factors. When we are blind to these issues, we negatively affect the plan of care and the health outcomes patients strive to achieve.

1. Know your patients’ complete story and the neighborhood in which they live

Providing quality health care is no longer about simply shortening patients’ length of stay in hospital and getting them home as quickly as possible. Nor is it simply about caring for patients’ clinical needs. Only by tailoring care models in all care settings to specific populations, can we really meet the needs of individuals like Sonia.

The CCAC’s Community Capacity Plan, developed in collaboration with the Mississauga Halton LHIN, Central West LHIN and Central West CCAC, revealed that the care coordination we provide should be tailored to individuals based on: their diagnosis, the neighbourhood in which they live and other social determinants of health – those social and economic factors, including education level, income, race, gender, sexual orientation and place of residence, which influence health and wellbeing.

If we don’t address social determinants of health and the contributing factors in each patient’s situation, we’re putting people like Sonia at higher risk of health complications, poorer quality of life, hospital admissions and readmissions and avoidable emergency department visits.

The evidence supports this. Data from the Mississauga Halton Community Capacity Plan found that seniors from the highest-risk Socio-Economic and Cultural (SEC) group were more likely to move to institutional care, or long-term care, than those from low SEC groups. They were also 40 per cent more likely to visit hospital emergency departments than individuals with low SEC status.

These at-risk patients can’t afford to follow health care direction without the necessary resources. If their income is used to support five family members, or if they live at home with a small support network like Sonia, priorities are more likely to focus on paying rent and purchasing food than on filling prescriptions or paying for transportation to a health clinic, for example.

In fact, a Health Quality Ontario report found that one in 12 Ontarians surveyed, aged 55 years and older, didn’t fill their prescriptions or skipped a dose because of cost, while another study found that one in eight Canadians between 55 and 64 years old will occasionally skip prescription medications for the same reasons. If we know patients can’t afford their medications, we should certainly be approaching their care differently.

As I mentioned in my first post, “5 Features of a Sustainable, Integrated Health Care System,” bringing care out of institutions and closer to patients’ homes lets us tackle socioeconomic obstacles. By asking the right questions in all care settings, we can move beyond clinical diagnoses, to having meaningful conversations with patients, engaging their families, and providing more comprehensive support services at home, in the community and in hospital.

2. Identify individual and systemic barriers that create inequities

After implementing the CCAC’s Care Coordination Program of Work a recommendation from the Community Capacity Plan – we saw the realignment of care coordination teams and service providers within the Mississauga Halton region. We identified 26 neighbourhoods of roughly 10 square kilometres each, as relevant for organizing care delivery in the community setting.

We now have teams who will really know the gaps that exist, which will allow them to better provide comprehensive care in neighbourhoods in which their patients live. For example, high utilization of certain services in a region helps us uncover the specific challenges the population in the area faces. Teams can proactively consider not only the clinical care needs but the supports required to address the SEC issues that impact a patient’s care plan.

The questions now are, how can we overcome the challenges of involving family physicians, pharmacists, nurses, hospital physicians, and others in the continuum of care, so that we can collectively wrap care around individuals more effectively and efficiently? How do we create high-performing care teams across the diversity of the independent programs and services that are available in the community?

Dr. Kwame McKenzie, Medical Director of Underserved Populations at the Centre for Addictions and Mental Health (CAMH), led an initiative to identify ways in which we can improve health equity in the country. He helped develop the following eight questions that health care professionals can ask their patients during the assessment process, which would then be shared with other health professionals:

  1. What language would you feel most comfortable speaking in with your health care provider?
  2. Were you born in Canada? (If no, what year did you arrive?)
  3. Which of the following best describes your racial or ethnic group? (list provided)
  4. Do you have any of the following disabilities? (list provided)
  5. What is your gender?
  6. What is your sexual orientation?
  7. What was your total family income before taxes last year?
  8. How many people does this income support?

These are questions that we don’t traditionally think about asking. They can be asked once by any health care professional conducting a patient’s initial assessment – either a family doctor, hospital discharge planner, nurse or care coordinator. The value of asking these questions is that health care professionals are able to have patients’ socioeconomic information at their fingertips. When they meet with patients for the first time, they will have a deeper understanding of their needs and the kinds of individualized questions to ask, to build an effective care plan that will enable patients achieve their health goals.

By acting on this data, we’re better equipped to reduce unnecessary hospital and emergency department visits and entry to long-term care. We’re also able to identify trends with patients over time, to understand risks to certain populations in the region, and to connect patients with the appropriate services in their neighbourhood.

Some organizations have begun collecting data on patients’ socioeconomic situations using these eight questions. Now we need to find a way to consolidate and share this information with everyone involved in a person’s care. As of today, we don’t have the means to share SEC scores at a patient level. Even though care providers may understand the importance of SEC status, when information isn’t shared, we see ourselves entering into the familiar cycle of asking patients to repeat their story over and over again.

The CCAC will continue using equity data collection to inform the delivery of quality care through its Care Coordination Program of Work, to ensure that care is wrapped around the patient at the neighbourhood level. Through our Client Health and Related Information System (CHRIS), we have the means to link with other systems and to share this information with those in the patient’s circle of care. Being able to share information effectively is one of the characteristics of high performing, patient-driven health systems, and leads to my third step to addressing socioeconomic barriers: effective collaboration

3. Bringing together clinical and social determinants of health through collaboration

Hospital physicians, clinicians, nurses, family physicians, care coordinators and others in the continuum of care must collaborate to help patients achieve what is most important to their wellbeing. Frankly, our patients expect this of their care team. We need to bring clinical and social determinants of health together.

By asking Sonia questions related to her socioeconomic status, we would know she feels more comfortable speaking Polish, that she is still mourning the loss of her husband, which led to her depression, that poor eating habits contributed to her type 2 diabetes and that she has a very small support system at home – issues that cannot be addressed through medication alone, but also through lifestyle changes, volunteer programs and other non-clinical supports.

Creating effective, accountable inter-professional teams through strong relationships with everybody in a patients’ circle of care is a must. As I mentioned in my previous post, “4 Ways Big Data Informs and Manages Health Care Performance,” we need an integrated system focused on system planning and patient-driven care delivery operations to ensure that individuals with the greatest needs receive comprehensive, individualized care. This includes supporting care coordination, monitoring quality, patient outcomes and their experiences and service providers’ resource use.

Standardizing clinical care pathways – management plans that display goals for patients – are a great move forward to improving clinical care outcomes for Ontario residents. Knowing SEC information, which allows us to wrap necessary supports around patients to help them achieve expected outcomes, is necessary for the individualization of care plans.

In my next post, I’ll delve a little deeper into the importance of collaboration and the ways in which it can expand health care capacity.

What do you think? Are you collecting SEC data? How is it helping you provide more effective care?  

4 Ways Big Data Informs and Manages Health Care Performance

Big data for health

computer system graphic with home care images showing how big data informs and manages CCAC patient care In my first post, I outlined five features of the patient-focused integrated health care system that I envisioned. The third feature is a system that: stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and social, economic and cultural (SEC) tools, among others.  This post focuses on part of this feature: the value of big data in health care performance.

Today, physicians, therapists, nurses and other clinical experts each use different tools to assess patients’ needs and record pertinent information to manage their care. The clinical expert learns about each patient, their past, current conditions and needs but once a patient  moves from one setting, like a family physician’s office, to another, like a hospital, the process usually repeats. Time is lost to redundant questions and similar assessments, while some details remain a mystery, known only to one setting’s care providers.

In the home and community care sector, we securely share our assessments, plus other data, within and across our CCACs to uncover evidence-based insights that inform and manage our patient care decisions. And when a hospital discharges a patient to a CCAC, which coordinates care with their service provider, the patient’s information follows them. But these scenarios are the exceptions. CCAC also coordinates care with other organizations in the patient’s neighborhood but the ability to appropriately  share that information in real time is currently not a standard.

For patients like Yasmin, a frail senior admitted to the emergency department with a broken leg, the clock ticks while her frantic husband recalls her medical history. Tests are run to assess her bone density, anesthetic threshold and other details her family physician already has on file. Meanwhile the backlog of aging patients with urgent needs builds.

To meet the needs of a rapidly growing older population with multiple or complex care requirements, there’s a rising imperative for more integrated systems. We need to access data from clinical experts across the continuum of care to see a complete picture of each patient, learn about the broader population’s needs and identify system opportunities to improve people’s experiences.

Organizations are working to eliminate redundancies by creating one electronic health record (EHR) for each patient, which is shared and understood across the continuum of care, but much needs to be done.

At the Canadian Home Care Association’s 2015 summit, I heard about Belgium’s work as one of the first countries to share a single assessment record per patient between multidisciplinary clinical experts and across various care settings. Dr. Anja Declercqu outlined how BelRAI, its evidence-based assessment solution, enables home care organizations, hospitals and long-term care homes to securely exchange patient data with each other. She also cited challenges, as health partners were still learning to trust each other’s assessments, but their progress was impressive.

If Yasmin lived in Belgium, all clinical experts would quickly know her history and conditions, as she moved between care settings to have her fracture set and safely return home to heal – faster and at less cost.

With a more integrated system, we will be able collaborate and coordinate our patients’ care with other members of their care team. Working together, will also deepen everybody’s understanding about the unique contributions each sector brings to the continuum of care and foster conversations about what needs to improve.

We are moving closer to this ideal in Ontario and can increasingly use big data to:

1. Address each patient’s needs

Care coordination begins with thoroughly assessing each CCAC patient’s health care and social needs, as well as learning about their goals. Our care coordinators combine this assessment data with their clinical expertise to inform decisions around a care plan that will best meet their patients’ needs. Ontario’s CCACs are gradually adopting InterRAI, an international version of Belgium’s BelRAI assessment solution, recognized worldwide for supporting best practice patient care. It will empower our frontline teams to develop more personalized evidence-based care plans, centred on each patient’s experiences and goals.  And in a patient-focused, integrated system, a patient’s single, electronic health record will follow them, as they move between care settings, versus multiple records across the continuum of care.

2. Understand neighbourhood level needs –

Data also helps us understand the patient populations our organizations serve. It shows us people often live near those who are like them and may think, work and even approach their health care in similar ways.  Through our Community Capacity Plan study, we learned that a community care organization delivers better patient outcomes if they are familiar with the neighbourhoods where their patients live and receive their care. Our Care Coordinators need to know their local supports to an in-depth degree so they can develop a sustainable care plan aligned with their patient’s neighbourhood.

Knowing this, we developed Socioeconomic and Cultural (SEC) tools to help us understand a population or neighbourhood through data, such as income levels, average persons per dwelling and the percentage of dwellings owned, versus rented. For example, this data shows us that patients in a neighbourhood with a high SEC, are 40 per cent more likely to visit the emergency department, than those in other areas with a low SEC.

Viewed together with other population health information, these data points build a picture of a neighbourhood’s needs. These insights inform current home and community care services, including those to address a patient’s social determinants of health, as well as their clinical needs.

This data helps identify areas where services are inequitably distributed and is invaluable to long-term health system planning. When we plan neighbourhood clusters or community service hubs of services, there’s no need to arbitrarily put a pharmacy here or a chiropractor there. We can drive these decisions by evidence-based patient population needs, which we know, right down to the postal code level.

3. Coordinate care across the province –

I wonder if many realize that CCACs have an electronic health record for every patient they serve.  Our Ontario-wide Client Health and Related Information System (CHRIS) was developed by our provincial organization and CCACs. We rely on this web-based system to manage all aspects of each patient’s care, along with reporting and finances.

eHealth Ontario used CHRIS as a core part of its ConnectingGTA solution for CCACs and hospitals across the megacity to securely share electronic health information about its residents.

We’re now looking for ways to extend CHRIS access to other partners in the system. Then, it could take us beyond neighbourhoods to uncover regional trends and identify barriers that may be limiting patient outcomes.

4. Monitor and optimize resources –

Data doesn’t just inform patient care decisions, it can also manage ongoing performance. To help our teams decipher the data they need to manage all aspects of each patient’s care in real time, we developed ‘Insights.’ 

On a personal level, this interactive dashboard enables care coordinators to measure their own performance against consistent guidelines for exceptional care.

From a broader organizational perspective, clinical managers can use this tool to track resource use, patient outcomes and performance to identify issues or best practices. But why stop here? Insights can be adapted and its scope expanded to oversee performance in other care settings for an integrated people-focused system.

Our community capacity plan showed us one of our biggest opportunities lies in leveraging our current resources to build capacity, including the people, technology and processes that define how we use data.

In 2013, we looked at data across all care settings to build a comprehensive picture of our community’s needs in the next 10 to 20 years, particularly within the borders of our Health Link neighbourhoods. We saw how hospital, long-term care, community support services and CCACs currently use resources and we identified opportunities for improvement. And we used modeling to project what optimizing those resources would look like, if we had no new money to where we should invest to create the best outcomes for our patients, when resources are available.

If our health partners effectively leverage our assets, we have a shot at reaching Belgium’s ideal and optimizing our ability to care for people across Ontario.

With its Patients First legislation, the Ontario Ministry of Health and Long-term Care intends to establish sub-regions (LHIN sub-regions) within local health systems to plan performance improvement and more equitably integrate services at a community level.

Our CCAC has been moving in this direction for some time, re-aligning our care coordinators and contracted service providers around neighbourhoods that are similar to LHIN sub-regions. This model offers several benefits. Among others, these include addressing socioeconomic impacts and inequities, which I’ll discuss in my next post.

What do you think? Are there other ways we can leverage big data to improve patient outcomes and experiences?