Abstract
Health status is greatly affected by social and environmental influences.1-3 These influences have resulted in potentially avoidable inequities and disparities in health status among populations.3-5 The increasing emphasis on recognizing and addressing social determinants of health can be seen in the evolving focus of Healthy People from 2000 to 2020. 4 In Healthy People 2000, the goals were to reduce health disparities, and in Healthy People 2010, the goals were to eliminate health disparities and finally, in Healthy People 2020, the goals are to achieve health equity among Americans. 4 In order to achieve health equity, interventions that foster health need to be targeted to all people, including those who have experienced obstacles to health based on factors such as race, ethnicity, or socioeconomic status. 4 Target goals for many treatable conditions such as high blood pressure and diabetes are well defined6-8 and are incorporated into Healthy People 2020 objectives. 9 An issue is how to ensure that people historically affected by factors related to race or socioeconomic status receive support in meeting those goals. One of the principles advocated by Braveman et al 3 is that resources needed to be healthy, including medical care, should be distributed fairly.
This article describes initial clinical outcomes achieved in a Center for Health Equity (CHE) created to help ensure that needed resources to achieve health were more fairly distributed among populations that needed them. The CHE was built by a large integrated health care system (Summa Health System, SHS) and a 4000-member church (The House of the Lord) in a neighborhood impacted by long-term disparities related to race and class. Funding and resources for the CHE were obtained from the House of the Lord, SHS, US Department of Housing and Urban Development grants, a federal appropriation for the purchase of equipment and medical supplies, tax credits, the Summa Foundation, and other local foundations.
The community that the CHE was designed to affect is located within Summit County, Ohio. More than 77% of the people living in 2 of the ZIP codes of the primary service area radiating 1.5 miles around the CHE are African American, and many of them are uninsured or underinsured. The CHE was created to provide culturally appropriate medical care within the community as part of a center that includes community rooms, a large kitchen, and computer facilities. The CHE offers lifestyle programs that encourage physical activity and healthy diet, such as line dancing and cooking classes, and community-desired events, such as diabetes education and chronic disease management. Program goals are developed and implemented using input from patients and community members in written format, surveys, question-and-answer sessions, and from a Community Advisory Board.
The center opened in March, 2012. The physician practice within the CHE is an independent site of a large multispecialty provider network. Physicians are hired by the network throughout Summit County and are able to accept patients with Medicaid, Medicare, and private insurance. The practice achieved level 3 recognition as a patient centered Medical Home by the National Committee for Quality Assurance in 2013. Primary care was provided by three physicians who are members of minority populations; the majority of nurses and medical assistants were also members of minority populations. The CHE attracts patients from Burmese, Nepalese, and Karen refugee communities who have limited English proficiency. One of the physicians spoke Nepalese and interpreters were provided for patients speaking languages other than English. Educational material was available in multiple languages. Training of providers related to culturally competent care and social determinants of health was provided formally and informally through fellowship training, continuing education courses, and staff workshops addressing health care disparities and health inequities. Patients’ stories and the social determinants of health were placed at the center of patient care and patients were encouraged to become involved in the health education and promotion activities at the CHE. Data are presented from the first 2 years the CHE was open to demonstrate the impact of providing culturally appropriate and patient-centered care within, and as part of, the community being served.
Methods
Data from all patient visits where blood pressure was recorded during the time period June 1, 2012, to June 30, 2014 were obtained. Patients with a systolic blood pressure ≥140 mm Hg at a first visit during the time period June 1, 2012, to June 30, 2013 were selected for analysis. The systolic value at this first visit was compared with the systolic blood pressure reading at their last visit through June 30, 2014. Diastolic blood pressures corresponding to the systolic pressures were also analyzed.
Patients with an HbA1c value ≥7% at a first visit during the time period June 1, 2012, to June 30, 2013 were selected. The HbA1c value at this first visit was compared with the HbA1c value at their last visit which occurred through June 30, 2014.
Patients with high blood pressure were treated according to JNC 7 Guidelines 6 ; patients with elevated HbA1c levels were treated according to evidence based guidelines from the American Diabetes Association 7 and the American Association of Clinical Endocrinologists. 8 The center uses electronic medical records and generates reports using MDinsight. Data were analyzed with paired t tests using SPSS version 22.
Results
Characteristics of patients seen at the CHE are provided in Table 1. Comparison with total patient visits indicated that blood pressure was obtained from virtually every adult patient seen for an initial appointment. During the first year, 390 patients with a systolic pressure ≥140 mm Hg were seen (Table 1). Of these patients, 358 came back for at least 1 visit (92%) and were included for further analysis (comparison of first and last visit; Table 2). Mean number of visits (±standard error of the mean) for these patients was 8.1 ± 0.2. By the time of the last visit, 70% had values <140 mm Hg. Instead of 39% having a systolic pressure >159 mm Hg, only 10% of patients had levels this high (Table 2). Diastolic blood pressure was also improved; by the last visit, 53% of patients had a diastolic value <80 mm Hg (Table 2). Mean values for systolic and diastolic pressure between the first and last visits were significantly decreased (mean systolic values decreased from 159.5 ± 0.8 to 134.4 ± 1.0 mm Hg, P < .001; mean diastolic values decreased from 88.9 ± 0.6 to 79.7 ± 0.6 mm Hg, P < .001).
Characteristics of Patients Seen During the First Year.
Abbreviations: BP, blood pressure; HbA1c, glycated hemoglobin.
Distribution of Blood Pressure and HbA1c Values at the First and Last Visits in Patients Who Presented With Blood Pressure ≥140 mm Hg or HbA1c Values ≥7.0% at the Initial Visit and Returned for at Least One Visit.
Abbreviations: BP, blood pressure; HbA1c, glycated hemoglobin.
During the first year, 88 patients with HbA1c values ≥7% were seen (Table 1) and 68 came back for at least 1 visit (77%; Table 2). Mean number of visits for these patients was 3.5 ± 0.2. By the last visit, 31% had values of HbA1c <7%. The change in mean HbA1c levels between the first and last visits was significant (mean HbA1c values decreased from 8.9% ± 0.2% to 8.1% ± 0.2%, P = .001).
Discussion
When the CHE opened, there was a rapid influx of patients requiring essential and basic primary care to treat conditions such as high blood pressure and diabetes. The majority of the patients treated for these conditions returned for multiple visits over the 2-year time frame included in this report. Although medication compliance was not directly measured, changes in blood pressure and HbA1c levels suggest they were compliant with treatment prescribed by the physicians.
A primary care center within a CHE that exists as part of a community is potentially able to overcome barriers to management of chronic health conditions at the individual, health system, and community level. 10 The CHE developed as part of an ongoing relationship between members of a health care system (SHS), the church, and members of the community. This was therefore not a situation where an outside organization came into the community, but rather one where members of a community worked to bring health care into their community. Because the primary care physicians were part of a large health care system that supported efforts to have the practice meet the highest standards of quality, patients consistently received evidence based care. Reproducible components include the practice of evidence-based care by practitioners trained in providing culturally competent care in a center where social determinants of health are acknowledged and patients are encouraged to participate in health education and promotion activities that have been developed and implemented in collaboration with the community.
Distrust of health care professionals can pose a threat to medication adherence. 10 This potential barrier may have been reduced by (a) using an interdisciplinary health care team consisting of professionals from like minority groups, (b) using patient-centered approaches to developing treatment plans, (c) having providers who spoke the native language of many of the patients, and (d) developing a sense of place. Specifically, the definition of patient-centered care as “respecting and responding to patients’ wants, needs and preferences, so that they can make choices in their care that best fit their individual circumstances”11(p40) is implemented at the CHE by incorporating input from patients and community members.
Limitations of the study include the possibility that factors other than those central to the vision and mission of the CHE were responsible for the improvement in clinical outcomes. The strength of the findings in this study, however, support the hypothesis that elements within the structure of the CHE contributed to the outcomes obtained. Improvements in blood pressure control compare favorably to results reported in previous studies. For example, Walsh et al, 12 in a critical review of 63 quality improvement studies aimed at hypertension care found a median increase in the proportion of patients with blood pressure in a target range of 16.2% and a median reduction in systolic pressure of 4.5 mm Hg and diastolic pressure of 2.1 mm Hg. Within our study, 70% of patients achieved a systolic blood pressure <140 mm Hg, and there was a mean change in systolic and diastolic pressures of 25.1 and 9.2 mm Hg, respectively. Recent studies using patient samples similar to the center only report nonsignificant reductions in systolic and diastolic pressure following patient centered interventions led by interdisciplinary teams.13,14 Cooper et al 13 reported a 13.2 mm Hg reduction in systolic pressure and Dennison et al 14 reported 3.7/4.9 mm Hg mean systolic/diastolic reductions after 1 year.
Improvements in blood pressure control appeared a little more successful than control of HbA1c levels. It may be that controlling blood pressure requires less lifestyle changes than controlling diabetes. Lifestyle changes such as increasing exercise and modifying dietary intake may be required for effective diabetes management. The goal of the CHE is to combine the strengths of a positive patient-physician relationship with accessible and relevant lifestyle programs. Data from this report demonstrate statistically significant improved clinical outcomes among members of this community who sought and received care from physicians within this CHE.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.