Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost - Call to Action for a System-wide Focus on Equity

Tremendous health outcome inequities remain in the U.S. across race and ethnicity, gender and sexual orientation, socio-economic status, and geography—particularly for those with serious conditions such as lung or skin cancer, HIV/AIDS, or cardiovascular disease.These inequities are driven by a complex set of factors—including distance to a specialist, insurance coverage, provider bias, and a patient's housing and healthy food access. These inequities not only harm patients, resulting in avoidable illness and death, they also drive unnecessary health systems costs.This 5-part series highlights the urgent need to address these issues, providing resources such as case studies, data, and recommendations to help the health care sector make meaningful strides toward achieving equity in specialty care.Top TakeawaysThere are vast inequalities in access to and outcomes from specialty health care in the U.S. These inequalities are worst for minority patients, low-income patients, patients with limited English language proficiency, and patients in rural areas.A number of solutions have emerged to improve health outcomes for minority and medically underserved patients. These solutions fall into three main categories: increasing specialty care availability, ensuring high-quality care, and helping patients engage in care.As these inequities are also significant drivers of health costs, payers, health care provider organizations, and policy makers have a strong incentive to invest in solutions that will both improve outcomes and reduce unnecessary costs. These actors play a critical role in ensuring that equity is embedded into core care delivery at scale.Part 5: "Call to Action for a System-wide Focus on Equity"These solutions create value not only for patients, but also for health care providers and public and private payers.  Each of these actors have a role to play in scaling and sustaining the health equity solutions.

Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost - Striving for Equity in Specialty Care Full Report

Tremendous health outcome inequities remain in the U.S. across race and ethnicity, gender and sexual orientation, socio-economic status, and geography—particularly for those with serious conditions such as lung or skin cancer, HIV/AIDS, or cardiovascular disease.These inequities are driven by a complex set of factors—including distance to a specialist, insurance coverage, provider bias, and a patient's housing and healthy food access. These inequities not only harm patients, resulting in avoidable illness and death, they also drive unnecessary health systems costs.This 5-part series highlights the urgent need to address these issues, providing resources such as case studies, data, and recommendations to help the health care sector make meaningful strides toward achieving equity in specialty care.Top TakeawaysThere are vast inequalities in access to and outcomes from specialty health care in the U.S. These inequalities are worst for minority patients, low-income patients, patients with limited English language proficiency, and patients in rural areas.A number of solutions have emerged to improve health outcomes for minority and medically underserved patients. These solutions fall into three main categories: increasing specialty care availability, ensuring high-quality care, and helping patients engage in care.As these inequities are also significant drivers of health costs, payers, health care provider organizations, and policy makers have a strong incentive to invest in solutions that will both improve outcomes and reduce unnecessary costs. These actors play a critical role in ensuring that equity is embedded into core care delivery at scale.

Effectiveness of Telemedicine in Diabetes Management: A Retrospective Study in an Urban Medically Underserved Population Area (UMUPA).

The purpose of this research is to assess the efficacy of employing telemedicine (TM) technology compared to traditional face-to-face (F2F) visits as an alternative healthcare delivery service for managing diabetes in populations residing in urban medically underserved areas (UMUPA). Researchers investigating public health and healthcare systems fully grasp the enormous challenges encountered by vulnerable populations as a result of healthcare access barriers.1 Prior to the COVID-19 pandemic, F2F visits were most often utilized for healthcare delivery service, which frequently posed barriers for vulnerable populations. When marginalized people, encounter healthcare access barriers, a cascade of events generally occur leading to forestalling or avoiding healthcare services entirely, complicating disease management, resulting in negative health outcomes. This was a novel study examining the hemoglobin A1c (HbA1c) values of 111 patients with uncontrolled type 2 diabetes mellitus (T2DM) and 81 patients with prediabetes. Retrospective electronic patient health records (PHR) from a medical clinic were examined from January 1st, 2019, to June 30th, 2021. The results indicate that lowering HbA1c values for T2DM patients through utilizing TM is similar to outcomes from traditional visits, suggesting that TM may be an alternative mode of healthcare delivery for vulnerable populations. Results for patients with prediabetes were not statistically significant. Patients with uncontrolled diabetes and prediabetes shared a number of similar characteristics; they were predominantly Black, non-Hispanic, females, with a median age of 57 years; and resided in locations with inadequate access to healthcare services in an UMUPA. The majority of patients with uncontrolled diabetes who reside in an UMUPA completed appointments utilized TM technology, lending credence to its potential as an alternative healthcare delivery service for underserved populations. TM technology supports PH and the healthcare system with a viable, alternative strategy for expanding healthcare access where chronic illness and disease pose a significant threat to the health and wellbeing of vulnerable groups. Optimal treatment for patients with diabetes necessitates a proactive, coordinated, systems-thinking team approach. This research supports PH’s endeavors in tackling the long-standing healthcare access barrier challenges in underserved populations

Assessing School-based Telehealth Utilization in Medically Underserved Communities

Medically underserved communities face challenges accessing health care services, and millions of Americans have no access to primary care. In many areas of the United States, the supply of primary care providers cannot keep up with the demand for health services. Newer healthcare delivery models are needed to address the issue. Using telehealth can augment the physician workforce shortages. The purpose of this quantitative dissertation is to examine the associations of telehealth utilization using a pediatric school-based telehealth model in Health Professional Shortage Areas (HPSAs) in North Texas. Texas has many counties without a primary care provider, making them medically underserved. The study uses data from a program designed by Children’s Health, serving school-aged children (ages 0-18) in 148 school sites across 5 counties. Approximately 12,471 telehealth visits occurred during the study period. The results revealed that telehealth utilization was significantly higher in HPSA zip code schools, and significant differences were observed in utilization patterns by race, age group, and school type. Additionally, provider status and insurance status were significantly associated with telehealth utilization. The significance of the study underscores the importance of telehealth and its value in serving medically underserved areas. School-based telehealth programs can promote positive societal change by addressing provider shortages and increasing access for underserved populations. The socioecological framework offers insights into social and environmental mediating factors. Additional research is needed to examine school-based telehealth program interventions further

Academic Health Science Centers and Health Disparities: A Qualitative Review of the Intervening Role of the Electronic Health Record and Social Determinants of Health

Literature on the magnitude of negative health outcomes from health disparities is voluminous. Defined as the health effects of racism, environmental injustice, forms of discrimination, biases in science, and sociological or socioeconomic predictors across populations, health disparities are part of an ongoing and complicated national problem that health equity programs are specifically designed to address. Academic Health Science Centers (AHC) institutions are a complex and unique educational-healthcare ecosystem that often serves as a safety net for patients in vulnerable and lower-income communities. These institutions are often viewed as one of the most uniquely positioned entities in the U.S. with an abundance of resources and networks to advance health equity as a high-impact goal and strategic imperative. Relatively little progress, however, has been made to better understand the potentially transformative nature of how digital health technologies (DHT)—such as mobile health apps, electronic health record (EHR) and electronic medical record (EMR) systems, smart ‘wearable’ devices, artificial intelligence, and machine learning—may be optimized to better capture and analyze social determinants of health (SDH) data elements in order to inform strategies to address health disparities. Even less has been explored about the challenging implementation of electronic SDH screening and data capture processes within AHCs and how they are used to better inform decisions for patient and community care. This research examines how AHC institutions, as complex education-healthcare bureaucracies, have prioritized this specific challenge amongst many other competing incentives and agendas in order to ultimately develop better evidence-based strategies to advance health equity. While there are clear moral, ethical, and clinical motives for improving health outcomes for vulnerable populations, when an AHC demonstrates that electronically screening and capturing SDH can improve the ability to understand the “upstream” factors impacting their patients\u27 health outcomes, this can inform and influence policy-level choices in government legislation directed at community-level factors. A qualitative thematic analysis of interview data from AHC administrators and leadership illustrates how AHCs have mobilized their EHR as a featured component of their healthcare delivery system to address health disparities, exposing other related, multifactorial dimensions of the Institution and region. Key findings indicated that: electronic SDH screening and updating workflow processes within an AHC’s clinical enterprise is a significant venture with multiple risks and the potential of failure. Universal adoption and awareness of SDH screening is hampered by notions of hesitancy, skepticism, and doubt as to an AHC’s ability to meaningfully extract and use the data for decision-support systems. Additional investment in resources and incentive structures for capturing SDH are needed for continued monitoring of patient health inequalities and community social factors. Data from this and future replicated studies can be used to inform AHC and government decisions around health and social protection, planning, and policy

Bringing Telemedicine Initiatives into Regular Care: Theoretical Underpinning for User-Centred Design Processes

Telemedicine is said to change the way care is delivered. Nevertheless, it still faces barriers to overcome the pilot stage and reach a majority of patients in regular care. Missing consideration of user-centred design processes is one major reason for this development as individuals are a key component for the technology’s success. Therefore, we aim to provide recommendations for a user-centred design process, which is, in turn, crucial to successfully implementing telemedicine innovations. To reach this aim, we identified individual-related barriers for telemedicine with an umbrella review. Furthermore, we related the barriers to the Unified Theory of Acceptance and Use of Technology (UTAUT2) proposed by Venkatesh and colleagues. A theoretical explanation helps to generate a broader understanding of what prevents individual acceptance of telemedicine innovations. The provided recommendations are supposed to support researchers and practitioners planning future telemedicine solutions

Current Practices, Perceptions and Challenges of Telehealth in the Treatment of Mental Health in the U.S. Department of Veterans Affairs

Currently there are 17,964,242 million Veterans living in the U.S. Around 50% of these Veterans are over 65 years of age. Many U.S. service members – both active and retired, experience trauma and dysfunction in restructuring their lives. Mental health problems are reported in over 50% of Veterans both in active service and retired. According to the U.S. Department of Veterans Affairs (VA), ten times more suicides are reported among Veterans who did not register with the VA compared to those who do register. Longer deployments, shorter times at home between the deployments and combat exposure are the greatest contributors of physical and psychological health problems. Combat exposure has been linked with most cases of PSTD. This creates a greater need for mental health services to Veterans than any other forms of treatment. Due to the complex nature of Veterans population, characterized by an aging majority and location of many Veterans in rural areas, delivering mental health services is a huge challenge for the VA. The VA has been making efforts to ensure that all Veterans can access mental health services from where they are. Out of these efforts, integration of telehealth services to improve access to mental health care services has yielded promising results but this is not without challenges. This dissertation explores the current practices, perceptions and challenges of telehealth in the treatment of mental health in the U.S. Department of Veterans Affairs (VA)

Organizational structure of telehealth care : an examination of four types of telemedicine systems

The purpose of this study is to make recommendations for a sustainable telemedicine system by examining the structural attributes of telemedicine across and within different types of organizations. A survey instrument with two categories, background questions and evaluation questions, was developed and used as a guide to interview eight key informants from four different types of telehealth systems. The eight transcribed interviews were coded using NUD*IST qualitative software. Research publications, archival documents, and government reports were collected to triangulate, or cross check, interview data. Multi-case study methodology was used as a guide to design the research, analyze date, compare results, and make recommendations. A telehealth typology is proposed as well as a simplified conceptual telehealth model and a diffusion of telemedicine model. While there are some structural differences among the different types of programs, there are many more similarities. All receive funding fiom multiple sources, and all employ a combination of full and part-time employees. Three core staff categories include administrative, medical, and technical support. Additional categories may include evaluation researchers and project coordinators

Closing the Gaps in Rural Healthcare in Texas: A Formative Bounded Case Study

Maldistribution of healthcare professionals persists in remote and rural communities throughout the world. Adoption of a Community Paramedic (CP) program could improve access to quality healthcare for rural communities. The conceptual framework defined rural communities by their distinct characteristics — community efficacy, weaknesses, attitudes, assets, deficits, local culture, and the driving and restraining forces — and not defined by their small populations or distances to cities. The theoretical foundation was a synthesis of theories of Bandura, Rogers, and Lewin. This study assessed community characteristics that may influence the likelihood of success, sustainability, or program failure of the Australian CP model in a single remote Texas border community. In this qualitative formative bounded case study, 3 bounded groups were examined; data collection was by in-person interviews. Group members were purposively selected: 5 residents and 3 EMS members. The 3rd group consisted of 4 randomly self-selected resident interviews, field observations, news articles, and local social media. Data transcripts were coded using theoretical coding based on the conceptual framework and theoretical foundation. Strong individual and group efficacy, efficacy resilience, adaptability, strong communications, overlapping groups, and a strong sense of community program ownership were evident in this study. The probability of establishing an effective CP program based on the Australian model is high based on study findings. Improved access to quality healthcare in remote and rural communities could result in improved health of community members and significant social change