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.
Society Hospital Medicine (SHM)
Evidence-based bundled intervention for hospitals to use to identify patients at high risk for readmission and guide the discharge plan based on identified needs assessed upon hospital admission; provides the patient a Transitional Record to guide them during the post-acute period.
Cost associated with implementation.
Central Massachusetts Community coalition in Partnership with Healthcentric Advisors
Decision Guide for Referrals to Community Based Organizations – A Tool for patients or a loved one.
The Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH)
The Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) has compiled Federal resources on the 2019 Novel Coronavirus (COVID-19) to assist our partners who work with those most vulnerable—such as older adults, those with underlying medical conditions, racial and ethnic minorities, rural communities, and people with disabilities.
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.
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
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:
- Discover and prioritize differences in care, outcomes, and/or experiences across patient groups
- Plan Equity-Focused Care Transformations and Measure Impact
- Tell the story of how patients experience health care