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One primary care practice used its efforts to stop avoidable readmissions and embed a patient-centered medical home model to help end health disparities.
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Using Meaningful Community Partnerships to Attain Health Equity

By IHI Multimedia Team | Thursday, November 16, 2017

Using Meaningful Community Partnerships to Attain Health Equity

How do you make ending health disparities more than just a noble goal? For a health system serving a diverse patient population near Philadelphia, Pennsylvania, one way is to train volunteer medical students to address patients’ non-medical needs. In the following interview, Chinwe Onyekere, MPH, and Barry Mann, MD, system administrator of Graduate Medical Education and chief academic officer at Main Line Health, share how the program began and the keys to the effort’s success. Main Line Health is one of eight health care organizations taking part in IHI’s Pursuing Equity initiative.

What is the Medical Student Advocate (MSA) program?

Chinwe Onyekere: The MSA program is our effort to identify and address the social needs of our patients in a medical setting. The MSAs are second-year students from the Philadelphia College of Osteopathic Medicine (PCOM) practicing at Lankenau Medical Associates (LMA).

Every patient who walks into LMA receives a survey that identifies their social needs. The survey asks about things like food, employment, child care, and transportation. Based on what they have identified, the MSA then follows up with a patient either at the time of their appointment or after.

Based on what the patient identifies as a priority, the MSA then works in partnership with the patient to find resources that are accessible to them. The resources should be either no cost or low cost and conveniently located for the patient. The MSA then connects the patients to those resources and follows up with the patient until their needs have been resolved. The MSA also follows up with the referring provider and documents all of their work in the electronic medical record.

What made your organization decide to create the MSA program?

Onyekere: Essentially, three of our initiatives serendipitously came together: 1) patient navigators as a way to address avoidable readmissions; 2) embedding a patient-centered medical home model into a primary care framework; and 3) systematically addressing social determinants of health to address key disparities in outcomes.

Barry Mann: To help us address the problem of [avoidable] readmissions, it was clear to me that we needed navigators to help patients resolve non-medical barriers to care and remind them how to take care of themselves post-discharge. It was also clear that the system could not afford all the navigators that were necessary. That’s when I suggested working with PCOM to see if they would allow us to utilize some volunteers from their second-year pre-clinical class.

Onyekere: While Barry and I were developing the MSA concept, we were also thinking about how to transform our primary care residency practice at Lankenau Medical Associates into a patient-centered medical home. To do this, we knew it would be essential to address the social needs of our patients.

The other impetus to create the MSA program was our work on addressing health disparities. We’re about to go into our seventh year of bringing together folks across the system to identify and address the social determinants of health that are major drivers of disparities in outcomes.

Mann: Our work on developing a patient-centered medical home and addressing health care disparities helped ensure that the MSA program had a home. Those things coming together made it real and helped it to get off the ground. It kept moving because it worked — it was good for patients and good for the students themselves.

What progress have you made so far?

Onyekere: The MSA program has demonstrated that it’s possible to engage medical students in identifying and addressing social needs, and benefit both our patients and our providers. We’ve also demonstrated that you can spread this kind of work. This is important because I think there’s often a lack of infrastructure to address social needs to pursue health equity. Providers can find themselves feeling frustrated because they don’t have the tools to address needs they know can be key drivers of their patients’ health outcomes.

For example, we have a project focusing on what we call “ED super-utilizers,” patients who have been seen and released from the ED three or more times in one year. One of our providers, Dr. Rose Finley, is a family medicine doctor who had a complex patient who had been to the ED more than 40 times in the past year. On average, he was in the ED once a week.

Dr. Finley wanted to help this patient see her in the primary care setting instead of going to the ED. We developed a multidisciplinary team with her as the lead. The team included a social worker, nurse case manager, clinical psychologist, and ED staff. The team identified that one of the patient’s major issues was no electricity in his home. He had been going to the ED to charge his phone and to eat. A social worker and an MSA were able to help the patient pay for electricity. The result is that the patient didn’t go to the ED for the next year.

What have been the most important factors contributing to your success so far?

Onyekere: We are fortunate to have an engaged and forward-thinking senior leadership team. They understand and are committed to addressing disparities of care. I think the other factor is having a committed clinical team who could appreciate that MSAs were going to help patients, and also make their own lives easier. They embraced it in a way that has allowed it to flourish, and then integrated it into how they deliver care.

We also have a history of piloting new ideas. We have a spirit of “Let's try it and see what we learn.” If a new idea doesn’t work we’ll scrap it, and if it does work we’ll continually innovate and refine.

Mann: I’ve also been very fortunate to work with Chinwe. Instead of banging our heads against the wall separately, we do it together!

What lessons learned can you share with others trying to address health equity?

Mann: Partnerships are the key to making this much bigger than a single institutional endeavor. We’re in the throes of developing that. Not all organizations are jumping to work with each other when they’re competing with each other for prestige, for patients, for grants, etc. But if you’re going to partner for the benefit of the community, you have to break those barriers. You need partnerships at the individual level, at the team level, and at the larger level.

Onyekere: We wouldn’t be able to do any of this without partners in the community. It was the relationship with PCOM that allowed Barry to pick up the phone, call the dean, and say, “We have this idea. Do you want to talk about it?”

The other piece that’s so important is trust, especially with issues as complex as disparities and institutionalized racism. It’s sometimes challenging for people to understand that we’re talking about systemic racism and not so much personal interactions.

How has being part of IHI’s Pursuing Equity initiative helped your efforts to address health disparities?

Mann: When we started the MSA program, the naysayers didn’t believe we could scale it up, but now we are. We’ve embedded medical students as MSAs in a federally qualified health center (FQHC) we’ve worked with for several years. There’s an ACO that’s part of our health system that covers 60,000 lives, and they’ve asked us to work with a subset of their population.

I think we’ve gained traction because IHI’s Pursuing Equity initiative has recognized the value of our efforts. This recognition has elevated the profile of the program and helped us gain additional buy-in from our president and our CEO.

Onyekere: The Pursuing Equity initiative gives us an equity framework and improvement tools (like PDSA cycles) to help us think about innovation, scale-up, and how to work in different kinds of community and clinical settings.

Being part of the Pursuing Equity initiative is also helping us give our providers the infrastructure to make interventions like the MSA program work. The last thing we want to do is ask patients about social needs without the system to address those needs. We’re trying to elevate social needs to the same level of importance as things like checking a patient’s hemoglobin A1c because improving both physical needs and social needs are important to improving outcomes.

Editor’s note: This interview has been edited for length and clarity.

You may also be interested in:

IHI white paper - Achieving Health Equity: A Guide for Health Care Organizations

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