Interventions that target multiple determinants of health are needed to improve health and achieve equity for all. The following excerpt from IHI’s Improving Health Equity: Address the Multiple Determinants of Health guide describes how to improve health equity throughout the health system.
Addressing areas outside of clinical care is critical for a health system to implement a holistic equity strategy. There are many areas health care can influence across its business and departments. Health care systems are large employers and have many business opportunities and decisions, all of which impact equity, whether intentionally or unintentionally. Health systems have an opportunity to be intentional in all of these decision points and policies in order to further equity, and it is critical to look at the impact across populations.
Health systems can:
- Engage in policy advocacy to improve equity
- Design equitable economic and professional development processes and opportunities for all health system staff
- Consider how hiring policies disproportionately advantage or disadvantage populations (e.g., a policy not to hire tobacco users which disproportionately impacts people of color and people with lower incomes)
- Procure supplies and services from women- and minority-owned businesses in the community
- Build health care facilities in underserved and less affluent communities
- Consider the community’s physical environment and the intersection of equity and access in:
- The health system physical environment (e.g., buildings, transportation, parking fees)
- Worksites, schools, and recreational settings
- Investment in housing, homes, and neighborhoods
- Reducing inequitable exposure, and exposure for all, to toxic substances and other physical hazards
- Removing physical barriers, especially for people with disabilities
- Review and update family policies ensuring that LGBTQ families are included in all benefits
- Aesthetic elements such as good lighting, trees, or benches in all locations
To address health determinants beyond inequities in clinical care, below we describe and share examples of how health systems can advance in two specific areas.
Design Equitable Economic and Professional Development Processes and Opportunities for All Health System Staff
Creating economic and development opportunities for the health care workforce requires establishing systems, structures, and policies to ensure that all staff have equal opportunity to thrive in the workforce. This requires health systems to review their current opportunities for staff; identify which staff utilize the opportunities and which staff do not, and the reasons why or why not; and assess the impact on employee retention, advancement, and joy in work. It’s also advisable for health systems to review these data stratified by race, gender, and other factors (e.g., women of color, LGBTQ staff).
Examples of changes tested:
- With a focus on wage equity, Vidant Health analyzed employee wages and identified that the lowest paid employees were women of color. Believing they could improve retention with higher wages, an important investment as the largest employer in their community, Vidant Health improved equity by increasing wages for these employees.
- Rush University Medical Center assessed access to professional development opportunities by understanding the breakdown by race and gender, and the intersection of these two, of who attends professional development trainings. For employees of lower socioeconomic status, in particular, paying for professional development fees out of pocket and then getting reimbursed was creating a financial challenge and a deterrent from taking advantage of this benefit. To impact equity and access to these resources, the medical center began giving employees a monetary advance to pay for professional development opportunities.
- In a discussion on internships and fellowships for clinical providers, Pursuing Equity teams raised the need for a health system to review and revise intern policies, namely, to assess the extent to which internships are paid and accessible to communities of color and low-income students. Unpaid internships are not options for many students and create an inequity in the prospective pipeline of the health care workforce. A health system can remedy this by providing paid internships.
Policy advocacy is a critical lever that health systems have at their disposal — to use their voices, resources, and support to impact the environment within which health care and communities are located. Advocacy can occur at the local, state, or federal level. To advocate for policies that improve equity, Pursuing Equity teams tested the following tactics: 1) establish relationships with policy makers to improve health and health equity in the community; 2) advocate alongside community-based organizations for improved access; and 3) work with state legislatures to revise payments and reimbursements for non-clinical health care providers.
Examples of changes tested:
- Main Line Health, along with more than 20 other health systems, academic institutions, and community organizations, established Together for West Philadelphia (TfWP) to facilitate collaboration among community, public, and private sector stakeholders on shared projects to maximize impact in the areas of health, education, food access, and opportunity. TfWP participated in the 2018 On the Table Philadelphia, an initiative to civically engage and identify opportunities to enhance the community and received $5,000 in grant funds to support five projects that arose from its discussions.
- In 2018, Rush University Medical Center implemented a patient transportation pilot program with Lyft, with the aim of using rideshare services to address the need for timely, effective, cost-efficient, short-term transportation options so patients can get to their medical appointments. This project was launched in response to the high rates of “no-shows” to outpatient medical appointments and the high rates of patients presenting to emergency departments with conditions that could have been managed in the outpatient setting. The partnership between Rush and Lyft began through Rush’s involvement with the Healthy Chicago Hospital Collaborative and is supported by various transportation efforts endorsed by the Department of Health and Aging and Department of Care Management. Areas testing this pilot program include the emergency department, inpatient units, adult primary care (three practices), pediatric primary care (three practices), the social work and community health department, and the population health program (which includes the Cancer Center, Medical Home Network [Medicaid ACO], and Transitional Care Program).
Challenges and Mitigation Strategies
- Impacting equity in the community, beyond the health system itself, can be challenging to coordinate. It also requires all health system staff have a shared understanding of equity and that leaders engaged in policy advocacy are utilizing an equity lens.
- Improving health equity throughout all areas of the health system, beyond clinical care, will challenge other priorities. For example, mandates to reduce the number of Medicaid patients being seen by the health system may negatively impact equity; increasing employee wages to improve equity for the health care workforce is an expense for the health system and requires buy-in from different stakeholders, from health system leadership to state and federal legislatures. Strong leadership commitment is needed to make equity a strategic priority, mitigate conflict when other priorities seem at odds with equity principles, and escalate challenges and make decisions that advance equity at key decision points.
Lessons Learned
Pursuing Equity teams learned that improving equity throughout and beyond the health system requires a strategy where staff and leaders in all departments can see how they contribute to the equity mission and are held accountable to do so. Leaders also need to make clear the organization’s long-term commitment to improving equity and how all departments and staff play a role in this important work.
Tools and Resources
To learn more, download the free Improving Health Equity: Address the Multiple Determinants of Health guide and the other Improving Health Equity: Guidance for Health Care Organizations publications.
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