A Health Equity Toolkit: Towards Health Care Solutions

For All

Bob GardnerSolutions: East Toronto’s Health Collaborative

January, 2014

Problem to Solve: Systemic Health Inequities in Ontario

clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health

the gap between the best off and most disadvantaged can be huge – and damaging

however measured -- by particular conditions, quality of life, life expectancy

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Gradient of Health Across Many Conditions

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Inequitable Quality

• from a resident participating in Wellesley community-based research in St James Town

“Language is a big barrier to us whenever we use any services. When our doctor is on leave then we are unable to visit a different one due to language problem. So we may have to go to a walk-in clinic or emergency. There were no interpreter services. I do not know if they arrange them in hospitals. I couldn’t follow what the doctor said.”

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Health Equity• goal of health equity strategy is to reduce or eliminate socially and

institutionally structured health inequalities and differential outcomes• positive and forward-looking definition = equal opportunities for good health• operationalizing equity in health care = providing care to meet different

needs of different patients and populations, in ways that reduce inequitable differences in outcomes:• understanding and addressing barriers to good care such as language and

misunderstanding/discrimination• recent immigrants need care that respects their cultures and

preferences and adjusts to their often more precarious economic situation

• understanding and addressing living conditions and social context of patients• poorer people face greater burdens and constraints on opportunities

for good health = need to take into account in care planning

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Towards Health Equity Solutionswill set out a toolkit of ideas, directions and techniques to build equity into healthcare planning and delivery• solidly based in research evidence

and years of best practice• action-orientated and manageable• measureable – so can monitor and

assess progress• adaptable to specific organizational

and local contexts• and can use to act well beyond

health system -- tackling the underlying roots of health inequality in the wider social determinants of health

the particularly good news = don’t need to start from scratch

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Todayequity toolkit• most ideas/initiatives will be familiar• but the great potential of networks like this is to identify community-level

challenges and opportunities, and to pull initiatives and elements together into a coherent overall equity strategy

was thinking of toolkit in three ways for Solutions:1. some parts of the toolkit can be adapted in your organization and sector

– where you’re a champion at organizational level2. some can help plan collaborative actions – potential of connected local

initiatives3. some are about identifying broader systemic and policy issues -- adding

your collective voice to efforts to shift policy or framing of equity at system level

will speculate on a few ideas and directions Solutions could consider7

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1. Start from Solid Foundations

• high-performing healthcare systems build equity into all planning and service delivery• doesn’t mean all programs are all about equity• does mean all programs and planning need to take equity into account

• need clear strategic commitment to build equity into system as a whole• LHIN, Ministry• cascading throughout all providers and programs so that equity

becomes part of working culture across the system• commitment has to be backed up by resources for equity planning and

operationalization• role for Solutions? – mbrs promoting this goal of embedding

across all their organizations and work

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2. Into Practice Through Equity-Focused Planning

• addressing disparities in access to or quality of health care requires a solid understanding of:• the contours and scale of inequitable outcomes• the specific needs of health-disadvantaged populations• gaps in available services for these populations• key barriers to equitable access to high quality care along

patient journey• at delivery level = considering equity in all program planning

• e.g. given importance of communications and understanding to quality care → need to ensure cultural competence, access to interpretation wherever needed, etc.

• need effective and practical equity-focused planning tools

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Tools: Always Plan through a Health Equity Lens

Role for Solutions? Advocate that all their member organizations use this type of basic equity lens routinely – from strategic to service planning

if this basic equity lens indicates there could be inequitable impact → then could drill down using fuller HEIA

Role for Solutions? Promote/enable use of HEIA within its organizations

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Could this program or policy have a differential and inequitable impact on some populations or communities?

How do we need to take the specific needs of disadvantaged individuals and communities into account in planning and delivering this service?

• analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations

• using HEIA can help • uncover unintended consequences or nuances easily missed in program planning• embed equity into routine planning processes and working culture• ensure that projects not specifically about equity or particular populations, will take

language, diversity, local community conditions, etc. into account• especially important for health service providers who are not experienced with

equity and for non-health organizations to take the population health impact of their policies into account

• growing, if uneven, use:• across LHINs -- Toronto Central has required HEIA within recent funding application

processes, and refreshing hospital equity plans → some hospitals have built HEIA into their routine planning processes

• adaptation geared to public health settings and standards been developed and promoted by Public Health Ontario

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3. Success Condition = Collect Equity Data

need solid equity-orientated data• to identify gaps and needs of

disadvantaged patients• to measure and monitor progress

pilot project in 3 Toronto hospitals (and Toronto Public Health) to collect patient SDoH type data scaled up to all hospitals in Toronto Central LHIN valuable website of resources on how to collect and use this data

role for Solutions: all members to adapt data collection model to their situations, as standardized as possible → building pool of SDoH data

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4. Build Knowledge We Can Act Onbase includes:• epidemiological research – scale of

disparities, disadvantaged communities/groups, community health profiles

• community-based research = especially unique understanding of needs and interests of marginalized or excluded populations

• evaluation –what works, for which populations, in varying contexts

• need forums to share lessons learned, emerging practices

systematic data collection + ability to measure/monitor /evaluate + broad research evidence = knowledge to guide/ground actionrole for Solutions? advocate for this broad understanding and bring solid community knowledge into planning

5. Beyond Planning: Embed Equity Into Targets, Deliverables and Performance Management

• clear consensus from research and policy literature, and consistent feature in comprehensive health equity policies and practice from other jurisdictions: • developing realistic and actionable indicators for more equitable

service delivery and outcomes• setting targets for reducing access differentials, improving health

outcomes of particular populations, etc• monitoring progress against the targets and indicators• disseminating the results widely for public scrutiny• aligning performance with funding incentives and resource allocation

• principle here = build equity into system drivers and trends• performance measurement and management are here to stay• emerging challenge = building equity/population health into

performance-based funding models

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Success Condition = Effective Equity Targets

• innovative work underway to develop comprehensive equity indicators – but don’t need to wait

• pick what is most relevant to your context:• do rates of post-treatment recovery and hospital re-admission vary

inequitably – by geography, ethno-cultural background, socio-economic status?

→ equity target = reduce inequitable differences• build equity into existing targets:

• e.g. reducing hospital admission rates for ambulatory sensitive conditions and diabetes are system goals

→ equity target = reduce inequitable differences in rates between different populations or areas

• role for Solutions? advocate within own organizations to build equity into scorecards and other performance measurement

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6. Embed Equity Into Organizational and System Drivers

• quality improvement is major provincial and system priority → embed equity

• patient-centred care + QI + equity = customized care to meet differing needs• social determinants disadvantaged populations face greater barriers beyond

the hospital and clinic walls • availability/cost of transportation, childcare, poor living conditions,

inequitable access to community services, discrimination, being able to afford medication

→ need more intensive case management, referral planning and post-discharge follow-up for those in more challenging/isolated conditions→ effective continuum of care and effective navigation/transitions is especially important for marginalized

• role for networks like Solutions? identifying what good linkages and comprehensive community support looks like for marginalized

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Use Proven Tools: Equity Standards

Canadian Health Equity Standards Working Group

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7. Use Available Levers To Embed Equity

• key priority for Ministry (therefore LHIN) and great potential to transform system = Health Links• considerable debate about whether starting assumptions of heavy

service users, etc., are right• but regardless of Min directions lots of innovative approaches on

how to build SDoH in• role for Solutions? explore project on how these and other ideas could

be developed into a comprehensive health equity toolkit for your Health Links • e.g. all HL to do community health mapping, identify priority and

under-served populations, adapt tools for customized care for marginalized, develop explicit equity indicators, etc.

• Solutions mbrs could take lead in promoting these tools and ideas in their HLs

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8. Target Access and Quality Barriers

improving equity requires identifying and addressing specific equity barriers • within delivery – language, lack of understanding of different cultures,

differential treatment, prejudice and discrimination, accessibility• beyond the clinical – e.g. sent home with follow-up prescriptions, but

don’t have a drug plan; can’t come into clinic for follow-up because of family responsibilities

• most important barriers will vary → back to importance of data and understanding health needs of community

another Solutions’ focus for Health Links?• population health profiles, health equity audits, community engagement

→ to identify most important local barriers and gaps

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9. Barrier = Under-Served PopulationsSolution = Focused Community Partnerships

given often higher care needs and less access to personal, family or community resources facing most marginalized:

• effective follow-up and referrals and good continuity of care, navigation and transitions are even more impt for the most vulnerable

• requires dense and connected web of community support

role for Solutions? fulcrum to strengthen collaboration among community agencies through an equity lens• focused on particular populations or

barriers

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10. Shifting the Policy Frame: Health = Healthy and Equitable Communities

what if hospital leaders said: we’re not the most important drivers of good health and we’re going to work with others to build healthier communities.

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role for Solutions? policy advocacy for key local issues, adding voice to wider campaigns, system issues

Pull All This Together into a Strategic

Roadmap

is there value in Solutions developing an equity plan?• what mbrs will do to promote

equity in their home orgs • what network can do to identify

most pressing common equity challenges and collaborative opportunities for change

can’t be a rigid blueprint, needs to be adapted and implemented flexibly to contexts and circumstances• but thinking of equity

roadmap helps to pull various initiatives into a coherent and connected plan