Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

National Association of Community Health Centers

Set of national core measures as well as a set of optional measures for community priorities. It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. It aligns with national initiatives prioritizing social determinants (e.g., Healthy People 2020), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-10, and health centers’ Uniform Data System (UDS).

Building an Organizational Response to Health Disparities: Five Pioneers from the Field

Centers of Medicare and Medicaid Services (CMS), Office of Minority Health (OMH)

Learn how five organizations have made a business case for addressing disparities in health care quality and access. Organizations such as hospitals, health plans, health systems, and others may see their own motivations and challenges reflected in these examples. These case studies increase the evidence base for health organizations in support of building a business case to reduce health disparities.

DISPARITIES IMPACT STATEMENT

Centers for Medicare and Medicaid Services (CMS), Office of Minority Health (OMH)

Learn how to identify, prioritize, and take action on health disparities by championing the Disparities Impact Statement in your organization. Participants receive personalized technical assistance focused on
strengthening your quality improvement program through a series of consultations from subject matter experts.

A Practical Guide to Implementing the National CLAS Standards: For Racial, Ethnic and Linguistic Minorities, People with Disabilities and Sexual and Gender Minorities

Centers of Medicare and Medicaid Services (CMS), Office of Minority Health (OMH)

The purpose of this toolkit is to enable organizations to implement the National CLAS Standards and improve health equity. It is organized according to the enhanced National CLAS Standards, and provides practical tools and examples of CLAS, in addition to efforts to implement the National CLAS Standards that can be adapted for use by health care organizations. It is intended for organizations that have already decided to pursue CLAS, to improve equity and eliminate health care disparities.

Guide to Developing a Language Access Plan

Centers of Medicare and Medicaid Services (CMS), Office of Minority Health (OMH)

Effective communication is critical to ensuring understanding, empowering patients, and providing high quality care. A language access plan can help ensure that an organization provides high quality and appropriate language services. This guide identifies ways that providers can assess their programs and develop language access plans to ensure persons with limited English proficiency have meaningful access to their programs.

Providing Language Services to Diverse Populations: Lessons from the Field

Centers of Medicare and Medicaid Services (CMS), Office of Minority Health (OMH)

Across the country, health care organizations are using innovative approaches to provide language assistance services to individuals with limited English proficiency. This resource discusses a number of approaches used by these organizations to provide language assistance services to persons with limited English proficiency based on the findings of case studies conducted with a variety of health care organizations.

Using Data to Reduce Disparities and Improve Quality

Advancing Health Equity (AHE)

Unless specifically measured, disparities in health and healthcare can go unnoticed even as providers, health plans, and governmental organizations (hereafter referred to as healthcare organizations) seek to improve care. Stratifying quality data by patient race, ethnicity, language and other
demographic variables such as age, sex, health literacy, sexual orientation, gender identity, socio-economic status, and geography is an important tool for uncovering and responding to healthcare disparities. This brief is organized into these three topics and recommends strategies that healthcare organizations can use to effectively organize and interpret stratified
quality data to improve health equity for their patients. It is intended for healthcare organizations and collaboratives that already have quality data stratified by one or more demographic variables. However, there are many resources on how to best collect and stratify race, ethnicity, language (R/E/L), sexual orientation, gender identity (SOGI) and other demographic data. Using stratified quality data strategically allows healthcare organizations to:

  1. Discover and prioritize differences in care, outcomes, and/or experiences across patient groups
  2. Plan Equity-Focused Care Transformations and Measure Impact
  3. Tell the story of how patients experience health care

Sepsis and Health Equity Fact Sheet

Sepsis Alliance

Highlights many racial, ethnic, and socioeconomic disparities related to sepsis. The fact sheet includes the following sepsis disparities:

  • Black and other nonwhite people have nearly twice the incidence of sepsis as whites
  • Non-Hispanic black children admitted to an emergency room are less likely to be treated for sepsis than non-Hispanic white children
  • Native Hawaiians have almost twice the burden of sepsis mortality compared to whites
  • Black children are 30% more likely than white children to develop sepsis after surgery
  • Children with severe sepsis or septic shock who are black or Hispanic are about 25% more likely to die than non-Hispanic white children
  • Adults below the poverty line have more than three to four times the risk of dying of sepsis compared to adults whose family income is at least five times the poverty line

Complex Care at NYC H+H: Operational Guide to Identify, Understand, and Treat High-Need Patients

NYC Health & Hospitals

This guide features open-source implementation tools which could be customized, and used to support other health system’s efforts to identify, understand, and treat patients with complex needs.
This guide provides step-by-step guidance on:
1) Risk scoring and stratification: using data and analytics to identify patients with complex needs;
2) Segmentation: combining analytics with clinical insight to understand patients with complex needs; and
3) Targeting: tailoring care models to fit needs and behaviors of patients with complex needs.

GRACE Team Care Model: Geriatric Resources for Assessment and Care of Elders (GRACE)

Agency Healthcare Research and Quality (AHRQ) & Indiana University School of Medicine’s Center for Aging Research

Designed as a promising solution to the health and health care challenges faced by low-income seniors with multiple chronic conditions, researchers at Indiana University developed the GRACE Team Care model  to assist primary care physicians (PCPs) working with low-income seniors to optimize health and functional status, decrease excess usage of health care services, and prevent unnecessary long-term nursing home placement.