Partnering Toward a Healthier Future 2013 PROGRESS REPORT Adventist HealthCare Health Equity Report
Compilation, analytics, and graphic design by Center for Health Equity and Wellness
Tiffany Capeles, MBA Nancy Flores Talya Frelick, MPH Marilyn Lynk, PhD Eme Martin, MPH Nadine Monforte Marcos Pesquera, RPh, MPH Deidre Washington, PhD
www.adventisthealthcare.com/disparities
Table of Contents Introduction
4
Background
6
About the 2013 Health Equity Report
10
Washington Adventist Hospital
15
Shady Grove Adventist Hospital
28
Adventist Behavioral Health
42
Specialty Care
53
Efforts to Reduce Readmissions
59
Conclusion and Next Steps
64
References
67
Introduction
Introduction | 5
Introduction In 2007, Adventist HealthCare created the Center on Health Disparities (CHD) to address and eliminate health disparities and inequalities in the communities served by the health system, with particular emphasis on Montgomery, Prince George’s, and Frederick Counties in Maryland. Health disparities are differences “in which disadvantaged social groups—such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination—systematically experience worse health or greater health risks than more advantaged social groups.”1 For more than 20 years, the Health and Wellness Department has worked with Adventist HealthCare health programs, such as cardiovascular, diabetes, cancer, and maternal and child health, to raise awareness of health issues, to screen for various conditions, and to offer educational and support programs to community members. The new Center for Health Equity and Wellness brings these two departments together to ensure that the communities served by Adventist HealthCare thrive in a culture of wellness and enjoy access to and the benefits of high-quality, equitable health care. OUR MISSION The Center for Health Equity and Wellness ensures the delivery of population-based care and promotion of healthcare equity in the communities served by Adventist HealthCare. We accomplish our mission by partnering with community members and organizations to implement health equity and community wellness approaches that improve population health. The work being performed at the Center contributes to the overall mission of Adventist HealthCare, which is to demonstrate God’s care by improving the health of people and communities through a ministry of physical, mental and spiritual healing. The Center works with different Adventist HealthCare entities to understand the diverse patient populations they serve; monitor differences by race, ethnicity, or preferred language in quality of care; and address disparities in order to provide high-quality and equitable care for all patients. For the second consecutive year, Adventist HealthCare is publishing a Health Equity Report to demonstrate how hospital patient data, including data related to core quality measures, readmissions, and patient experience, can be analyzed through a health equity framework to identify and address possible disparities in health care. In 2012, we explored the data collected at Adventist HealthCare hospitals and how they could be used to inform strategies to address community needs. This report will take an additional step forward to highlight the strategies and initiatives that are planned or already in place to move toward a healthier future for all. The continuing evolution and dissemination of this report demonstrates Adventist HealthCare’s commitment to transparency and accountability for performance excellence.
Background
Background | 7
Background MANAGING POPULATION HEALTH In the 2012 Health Equity Report, we discussed compelling reasons why hospitals should focus on reducing health disparities and improving quality of care for all populations. Changes in demographic patterns and healthcare policies in our nation, and reporting requirements for performance measures and patient experience by race and ethnicity, are just a few. Federal and state laws (e.g., health reform provisions to improve access, quality of care, and prevention strategies) compel hospitals to not just provide care to sick individuals, but invest in keeping whole populations healthy. Population health is a way of describing the health status and outcomes of people living within a community; it requires understanding why some populations are healthier than others. The ultimate purpose of population health is to improve the health of individuals and populations by investing in the determinants of health—social, economic, and environmental factors that influence a population’s well-being—through policies and interventions that affect these determinants.2 Population health outcomes are the product of multiple determinants of health, including medical care, public health services, genetics, behaviors, cultural background, health beliefs or practices, and policies, as well as social and environmental factors.3 However, health status is affected by a broad array of determinants, not only in health care or public health.4 Population health focuses greater attention on the influence of health disparities—differences in health outcomes that are often linked to social, cultural, and economic disadvantages. For instance, infant mortality rates are almost three times higher for Blacks compared to Whites across all income and insurance groups; Hispanics are four times less likely to have health insurance compared with other racial and ethnic groups; and the rate of new HIV cases for Blacks is more than 10 times the rate of that for Whites.5 These differences are often considered not only avoidable, but unfair and unjust.6 Racial and ethnic minorities, among other disadvantaged groups, tend to receive a lower quality of care than non-Hispanic Whites regardless of healthcare-related factors such as insurance, or other socioeconomic factors.7 For this reason, health disparities are also known as “health inequalities” or “health inequities”, terms that may better capture the unfairness of the differences many are working to eliminate. Though there has been significant progress in improving the health of populations in Maryland and nationwide (e.g., mortality rates for a number of diseases and conditions have declined), racial and ethnic minorities and low-income populations remain disproportionately affected by poor health outcomes compared to non-minority and high-income populations.8 Disparities are pervasive and must be addressed; however, healthcare providers and systems often see themselves as responsible for just some of community health and health care. For example, the Model of Health Improvement posits that hospitals and healthcare systems have significant control over 20 percent of input related to clinical care and shared control over 30 percent related to health behaviors, but limited control and capabilities to address socioeconomic factors and the physical environment.9 IMPACT OF HEALTHCARE REFORM ON POPULATION HEALTH The Patient Protection and Affordable Care Act (ACA) of 2012—also known as the healthcare reform bill— expands coverage to millions of individuals and families in need of health care. Healthcare reform impacts population health in four ways: (1) expanding insurance coverage to improve access to the healthcare delivery system, (2) improving the quality of care delivered, (3) enhancing prevention and health promotion measures within the healthcare delivery system, and (4) promoting community- and population-based activities and providing incentives for workplace wellness programs.10 Focusing on access, equity, quality, and prevention, the ACA provides resources to help promote prevention and wellness strategies that improve the health of people and communities and keep them healthy. Also, the ACA seeks to address disparities and promote health and healthcare equity among populations at risk.11 For several years, healthcare reform has been on the forefront of people’s minds when it comes
8 | Background
to equity, social justice, and access to health care. A large number of Americans who previously had no health insurance for instance, will now have access to care. However, access to health care does not necessarily mean that the care delivered will be patient-centered, high-quality or equitable. Improving health for all depends on equality in access to care and care utilization that leads to high-quality health care, and addresses disparities among different populations, so that all populations have an opportunity to reach their full potential for good health.12,13,14 THE ROLE OF HEALTHCARE SYSTEMS The focus on population health represents a shift in the field of public health; understanding and managing it will become more and more integrated into the role of healthcare providers. Hospitals not only have to rely on demographic and clinical data to identify populations in greatest need, but also analyze those needs, prepare comprehensive reports, and leverage existing resources in attempts to reach and support community members.15 Limited resources should be used to focus on the most pressing needs with the biggest possible impact. Furthermore, because hospitals and healthcare systems have limited control and capabilities to address socioeconomic factors and physical environments, collaboration with community stakeholders is essential. The American Hospital Association encourages hospitals to adopt population health management strategies because with healthcare reform, it is imperative that stakeholders and community members work in partnership. Healthcare reform is driving healthcare systems and hospitals toward a new role of shared accountability in population health management to explore new methods of care delivery.16 PROVIDING POPULATION-BASED CARE Managing population health means having an effective, collaborative strategy for improving the health of all communities and reducing inequalities in health outcomes between different populations. However, promoting the good health of the community has to become more than just a mission statement. After analyzing the distribution of health outcomes in different populations, providers must find ways to improve the population’s health that are tailored to meet community needs while leveraging their assets. Hospitals and healthcare systems can ensure that they are promoting efficient care by: (1) increasing the prevalence of evidence-based prevention health services, (2) improving quality of patient care, and (3) enhancing care coordination.17 Currently, chronic conditions account for more than 75 percent of U.S. healthcare costs.18 One goal of population-based care has been described as moving from treating chronically-ill individuals to having a chronically-well population.19 Adventist HealthCare (AHC) is dedicated to achieving performance excellence, expanding access to care, and providing population-based care, all integral parts of the organization’s 2010–14 strategic plan. AHC hospitals and their boards have focused their strategic priorities to make population health a central theme, reallocate resources, and commit to changes. A population-based health approach recognizes that achieving positive health outcomes for everyone in our communities is a shared responsibility. Such collaborative efforts require partners to share responsibility and accountability for collecting data systematically or merging existing data, identifying factors that influence population health, measuring outcomes, and addressing determinants of health through policies and interventions. Partners include healthcare delivery systems, public health agencies, national and local entities, primary care entities, and community-level organizations as well as stakeholders in other, nonhealth sectors such as schools and businesses.
“Equity in access to health care implies that everyone has the opportunity to reach their full health potential; in short, the playing field is leveled for all individuals.”20
Community Health Needs Assessment To improve population health, the Affordable Care Act (ACA) calls for nonprofit hospitals to assess the health needs of community members, implement strategies that meet those needs, and demonstrate community benefit. Under the requirements of the ACA, all 501(c)(3) hospitals must conduct a Community Health Needs Assessment (CHNA) to identify health or health-related problems and unmet needs, as well as existing resources among populations in their service area. A CHNA must be conducted every three years and the hospital must adopt an implementation strategy to prioritize and address the needs identified in the CHNA to improve the health status of people and communities in their service area. When an organization owns more than one hospital facility, a separate CHNA must be conducted for each facility. These requirements, which first began on March 23, 2012, now take effect every taxable year. In 2013, Adventist HealthCare’s Community Benefit Council collaborated with its Advisory Board, community leaders, community-based organizations, public health stakeholders, and the community to conduct a needs assessment for five of its entities—Shady Grove Adventist Hospital, Washington Adventist Hospital, Adventist Rehabilitation Hospital of Maryland, Adventist Behavioral Health ‑ Rockville, and Adventist Behavioral Health-Eastern Shore to determine the health needs of community members and develop implementation strategies to improve population health. Below is a summary of information gathered to develop the CHNA and the implementation plans for Shady Grove Adventist Hospital and Washington Adventist Hospital. Complete Community Health Needs Assessment reports for all entities will be available on the Adventist HealthCare website by the end of 2013. The implementation strategies for Shady Grove and Washington Adventist hospitals have been posted on the Adventist HealthCare website; implementation strategies for the three specialty care hospitals will be available by the end of the second quarter of 2014. Shady Grove Adventist Hospital (SGAH) serves residents of Montgomery County, Maryland, primarily (88.2% of discharges). Within the hospital’s Community Benefit Service Area (CBSA), approximately 41.6 percent are minorities. The Shady Grove Adventist Hospital Board of Trustees and the Adventist HealthCare Board of Trustees each reviewed and approved two priority areas for SGAH’s implementation strategy in response to the CHNA findings: lung cancer in the Asian population and diabetes among Montgomery Cares (uninsured) patients. Compared to hospitals nationally, SGAH has a higher incidence of lung cancer patients in the Asian population (9.9% compared to 1.8%, nationally). One goal for the implementation strategy is to improve early screening and detection of lung cancer in the Asian population served by SGAH, to improve their five-year survival rate. Findings from the SGAH needs assessment also show that diabetes is the eighth leading cause of death in Montgomery County and it disproportionately affects minority populations and the elderly. The second priority for implementation is to improve the percent of patients who receive the recommended number of hemoglobin A1C screenings each year among known diabetic patients in the Montgomery Cares Program (uninsured) within SGAH’s service area. Washington Adventist Hospital (WAH) serves residents of Prince George’s County (44.5% of discharges) and Montgomery County (40.3% of discharges), Maryland, primarily. Washington Adventist Hospital’s CBSA serves a highly diverse patient population; approximately 66.5 percent of their patients are non-White minorities. Based on the results of its CHNA, WAH’s President’s Council decided to focus its implementation strategy on behavioral health and influenza prevention. Statistics from WAH’s needs assessment show that the rate of hospital discharges for bipolar disorder increased for Montgomery County adults and there was a two-fold increase in readmissions in the past decade. Among several interventions to address these needs, WAH plans to establish a transitional care plan for discharged patients with bipolar disorder, and refer patients admitted for substance abuse or alcohol abuse to appropriate resources for intervention and follow-up. Additionally, results revealed high emergency department visit rates due to immunizationpreventable influenza and pneumonia. To address this need, WAH will provide a combination of free and low-cost influenza vaccinations to residents in target areas.
About the 2013 Health Equity Report
About the 2013 Health Equity Report | 11
About the 2013 Health Equity Report Adventist HealthCare, Inc.(AHC), is an integrated, healthcare delivery network that includes five nationally accredited, acute-care and specialty hospitals, mental health services and home health agencies, serving the Maryland and the greater Washington, D.C. metropolitan area, and northwestern New Jersey. The 2013 Health Equity report includes patient data from both of AHC’s two Maryland-based acute-care hospitals: Washington Adventist Hospital (WAH) and Shady Grove Adventist Hospital (SGAH). For the first time, this year’s report also features data from AHC’s specialty care entities: Adventist Behavioral Health (ABH), Adventist Home Care Services (AHCS), and Adventist Rehabilitation Hospital of Maryland (ARHM). The organization of the report is described below. SNAPSHOT OF DIVERSITY For each AHC entity, we begin with a Snapshot of Diversity, which describes the entity’s patient population in 2012, stratified by patients’ self-reported race/ethnicity. As defined by the United States Office of Management and Budget (OMB), ethnicity and race are two separate constructs. Ethnicity is defined as either Hispanic or Latino (or of Spanish origin), or not Hispanic or Latino. OMB defines race using five categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White. Hispanics can be of any race. Both ethnicity and race should be self-reported by the patient. For the purposes of this report, we use the term Hispanic for any patient who has identified as such, regardless of their identified race. We use the race categories Asian, Black, and White for any patient who has identified as such, and has not identified as Hispanic. The category Other designates a patient who has self-identified as American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, any other race, or who does not identify with any of the five OMB categories. With the exception of AHCS, for which we used data from a report to the Maryland Health Care Commission, data for the Snapshot of Diversity sections were obtained from patient electronic medical records. For all entities, some patient race and/or ethnicity data was unknown and/or missing. Note: In previous reports, the Snapshot of Diversity and Where We See Our Patients sections included all patient encounters; that is, the same patient was counted more than once if he/she was seen in the same setting (inpatient, outpatient, or emergency department) more than once. This year, the Snapshot of Diversity includes data that distinguishes unique patients from all patient encounters (i.e., total volume). When reporting unique patients, if a patient was seen in the same setting multiple times, only their first encounter is included. However, if a patient was seen in two different settings on separate occasions, both encounters are included (e.g., once as an inpatient and once as an outpatient). In subsequent sections, the analyses reflect all patient encounters, unless otherwise specified. LANGUAGE PREFERENCE AND INTERPRETER SERVICES In addition to race and ethnicity, language preference is another important demographic characteristic to consider when describing the diversity of the hospital patient population. AHC is committed to providing high quality care to all patients in the language in which they prefer to communicate, including sign language in addition to spoken language. Effective patient-provider communication is essential to providing patient-centered care and is necessary for patient safety. AHC continues to provide various language service options for the limited English proficient (LEP) population that we serve. These options include onsite full-time Spanish interpreters, Qualified Bilingual Staff, on-call contracted interpreters, video remote interpreting for the Deaf and hard-of-hearing, and a telephone interpretation service that provides foreign language interpretation in more than 180 different languages, seven days a week, 24 hours a day. In Language Preference and Interpreter Services, for the two acute-care hospitals, we describe the patient population by preferred language. For all entities, we describe the usage of over-the-phone interpretation for the past year.
12 | About the 2013 Health Equity Report
Within Language Preference and Interpreter Services, data related to the patient’s preferred language were obtained from patient electronic medical records. For some patients, data on preferred language was unknown and/or missing; this is reflected in the tables and figures. There are numerous encounters that are not reported here (i.e., with full-time interpreters and Qualified Bilingual Staff); however, we are working to document the use of these services at our hospitals and other entities. All data pertaining to the use of over-the-phone interpretation were obtained from the vendor that provides this service to all of AHC. IN-DEPTH: HOSPITAL SETTING, HEALTH INSURANCE, AND PRIMARY DIAGNOSES For WAH and SGAH, the In-Depth sections provide a detailed look at the hospital settings in which patients were seen (inpatient, outpatient, and emergency department), primary diagnoses, and primary health insurance coverage stratified by race/ethnicity. For ABH, the In-Depth section includes data on health insurance, as well as primary patient diagnoses. Specialty Care sections (AHCS and ARHM) include health insurance data and primary diagnoses (AHCS only). For all entities, data on the setting, diagnoses, and insurance were obtained from patient electronic medical records. Any of the hospital settings described above may be an appropriate place to seek care; we make no assumptions or conclusions regarding the appropriateness of any encounter based on this data. However, higher rates of emergency department utilization may be associated with lack of a primary care physician or medical home, or being uninsured or underinsured.21 By examining these characteristics over time, patterns may emerge that illuminate racial/ethnic differences in both healthcare-seeking behaviors and access. Note: For ease of reporting, a basic, five level categorization scheme was developed to identify the patient’s primary health insurance coverage. The categories include: Self-Pay (uninsured or underinsured), Medicaid, Private Insurance, Medicare, and All Others. This scheme differs from the data requirements used for state reporting to the Maryland Health Services Cost Review Commission (HSCRC). Private insurance, for example, includes managed care organizations, health maintenance organizations (HMOs), and commercial payers, which differs from the HSCRC data reporting requirements. Therefore, the data reported here will not align with the data reported to HSCRC. INPATIENT QUALITY MEASURES For WAH and SGAH, in the Inpatient Quality section, we describe the overall scores for inpatient quality core measures: pneumonia, heart failure, acute myocardial infarction and surgical care. A total of 50 measures were collected at both SGAH and WAH ranging in scores from 91.43 percent to 100 percent. The data shown represents the overall summation of all patients and measures within each of the core areas at the hospital. For example, the pneumonia care data represents the summation of six individual measures related to the quality of care for patients with pneumonia. The data is presented this way because of the overall high scores achieved within and across each of the measurement groups. This also did not allow for statistical calculations of differences between racial and ethnic groups. The inpatient quality measures were abstracted from the Quantros platform used by AHC for core measure reporting. For ABH, the quality measures are from the Hospital-Based Inpatient Psychiatric Service’s (HBIPS) Core Measure Set, which consists of seven measures to assess quality of care for patients discharged from free-standing psychiatric hospitals and acute-care hospitals with psychiatric units. Information on five of the seven measures are presented and stratified by race. Looking ahead to 2014, the Maryland Health Care Commission (MHCC) will be adopting an expanded hospital quality data collection policy. This change will serve to “expand Maryland’s system for monitoring and public reporting on hospital performance and quality” and increase alignment with the Centers for Medicare and Medicaid’s (CMS) hospital quality program.22 With this expansion, there appears a trend that seems to be shifting focus from inpatient to outpatient measures.
About the 2013 Health Equity Report | 13
In recent years, a significant amount of change has occurred around inpatient measures. Among the core measurement groups described in this section, many of the measures have been retired leaving only two each for acute myocardial infarction and pneumonia, one for heart failure, and seven for surgery to be reported in 2014. While these measures have phased out, others have been added. In 2013, measures consistent with the CMS Value-Based Purchasing and Meaningful Use Programs were adopted. Outpatient measures to be collected in 2014 fit into three categories: claims based imaging efficiency (7), chart abstracted (13) and structural (4). In the chart abstracted category, measures focus on acute myocardial infarction and chest pain, emergency department throughput, stroke, and surgical care. The structural measures will require hospitals to report whether certain activities are performed such as tracking clinical results between visits and utilizing a safe surgery checklist. HOSPITAL READMISSIONS One of the provisions in the Affordable Care Act addresses the high rate of readmissions. Hospital reimbursements can now be adjusted based on higher than expected readmission rates.23 Hospital readmission rates can vary depending on several different factors, including income, race, health condition, hospital, patient case mix, and insurance coverage. In some instances, a hospital readmission may be appropriate and/or unavoidable. However, lack of post-discharge care coordination, disease management, severity of illness, medical errors or adverse events, poor patient adherence to the treatment plan, or ineffective communication, may result in a readmission that is potentially preventable. Both acute-care hospitals participate in the HSCRC Admission-Readmission Revenue (ARR) program, a voluntary revenue constraint program that provides hospitals with a financial incentive to coordinate care and reduce unnecessary readmissions. As reported in the HSCRC post-meeting minutes dated April 10, 2013, from FY2011 to FY2012, Maryland hospitals reduced readmissions by 6.7 percent and admissions by 3.5 percent.24 Based on this, HSCRC is recommending that all Maryland hospitals not participating in the voluntary program be required to implement the ARR/Charge Per Episode (CPE) policy. With the understanding that many factors may influence the likelihood of readmission, hospitals can collaborate with various community partners and develop innovative programs to reduce potentially preventable hospital readmissions. The Readmissions section presents 30-day all cause readmissions data, stratified by race/ethnicity. The readmission logic used for this analysis followed the HSCRC ARR methodology. Under this methodology, a readmission takes place when an admission occurs within 30 days of the previous discharge to the same facility. The number of discharges included in this analysis excludes zero and one-day stays per HSCRC guidelines, and it also excludes readmissions. Our data model does not include case mix adjusted data. PATIENT EXPERIENCE: RESPONSES TO THE HCAHPS SURVEY Research shows that a number of factors such as age, health literacy or education level, health status, and race/ethnicity or cultural beliefs can affect ratings of care.25 Although Latino and African Americans typically provide higher overall ratings of care, more information is needed to determine whether differences in ratings stem from actual differences in quality of care or from differences in patient perceptions, expectations or response styles.26 To further explore this area, in this year’s Health Equity report, we present responses to selected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions stratified by education level. A survey of over one million patients discharged between 2006–2007 showed that while health status, race, and language variables are strong predictors of HCAHPS performance, patient education and age contribute moderately to overall patient satisfaction.27 In the Patient Experience section, we present responses to items about patients’ experiences and satisfaction with care from the HCAHPS, stratified by (1) race/ethnicity and (2) education level (highest grade or level of school completed). HCAHPS survey data were obtained directly from the HealthStream
14 | About the 2013 Health Equity Report
(HSTM) Insights Online database; HealthStream is the vendor that administers this survey. This survey is only applicable to inpatients; it was administered to a sample of discharged patients and participation was voluntary. The percentages in the tables represent the top box score, which is the percent of patients who responded positively to composite and individual survey items (i.e., “Always”, “Definitely”, or “Yes” responses) or rated items on a scale from 1 to 10, positively (i.e., if 10 is the highest rating on a scale of 1 to 10, the percentage of patients who responded either 9 or 10). In the tables, the column labeled HSTM contains the top box scores that represent the 50th percentile of national hospitals in the HealthStream database. ADVENTIST BEHAVIORAL HEALTH In alignment with the theme of the 2013 Center on Health Disparities Annual Fall Conference, “Partnering Toward a Healthier Future: Addressing Disparities in Behavioral Health,” we devote one section to the issue of mental and behavioral health in the United States, highlighting the patients and work of Adventist Behavioral Health (ABH), which has facilities in both Montgomery County and Dorchester County in Maryland. The facility in Montgomery County primarily serves patients of all ages from Montgomery, Prince George’s, and Frederick counties. The facility in Dorchester County primarily serves the pediatric population of Dorchester and Wicomico counties. Prior to presenting patient data, the ABH section begins with background information on mental and behavioral health on national, state, and local levels. Due to the very different populations treated at each location, most of the data for ABH are presented by location. ADDITIONAL HIGHLIGHTS Special highlights in the report include information about federal standards to increase culturally competent care and reduce health disparities, the implementation of the Affordable Care Act (ACA) in the state of Maryland, efforts to reduce readmissions and improve patient-centered care across the Adventist HealthCare system, and AHC hospitals’ community health needs assessment results. The report concludes with Next Steps for all hospitals striving to implement a data-driven health equity agenda to achieve patient care that is high-quality and accessible across the state of Maryland. The primary goal of this report is to share demographic, clinical, and quality information about AHC hospitals and other entities, and highlight efforts to improve patient experiences and outcomes in the communities we serve. A majority of the information is descriptive and analyses are exploratory; detailed discussion and interpretation of findings is beyond the scope of this report. Nevertheless, we hope the information will be used by our hospital leadership to inform overall strategies and interventions that will have a positive impact on the health of populations.
Washington Adventist Hospital
16 | Washington Adventist Hospital
Snapshot of Diversity Both Table 1 and Figure 1 below show the distribution of all unique patients at Washington Adventist Hospital (WAH) in 2012, by race and ethnicity. WAH is located in Takoma Park, Maryland. As shown in Table 1, Black patients continue to make up the majority of patients treated at WAH. Black patients accounted for approximately 41 percent of WAH patients. Hispanic patients accounted for about 32 percent of WAH patients, White patients accounted for about 18 percent, and Asian patients accounted for 4 percent. These percentages are very similar to those described in last year’s report. (Note: See “About the 2013 Health Equity Report” for details on methodology, sources, limitations, inclusions/exclusions, missing data, and other information about the data reported here.) TABLE 1 AND FIGURE 1. ALL UNIQUE PATIENTS BY RACE/ETHNICITY, WAH, 2012 (N=57,546)
Race/Ethnicity
Percent (%)
Black
40.7
Hispanic
31.5
White
17.7
Asian
4.2
Other
3.2
Unknown
2.6
Total
99.9%*
Other Unknown 2.6% Asian 3.2% 4.2%
White 17.7%
Black 40.7%
Hispanic 31.5%
*Percentages do not add up to 100 due to rounding. All patients are included in computations.
Table 2 and Figure 2 below show the racial/ethnic distribution for all patient encounters at WAH in 2012. In the table and figure below, the same patients may be included multiple times. In 2012, there were more than 88,000 total patient encounters at WAH. A majority of the patient encounters is comprised of Black patients (43%) and Hispanic patients (29%); the distribution is very similar to that in Table 1 and Figure 1 above (unique patients). TABLE 2 AND FIGURE 2. ALL PATIENT ENCOUNTERS BY RACE/ETHNICITY, WAH, 2012 (N=88,458)
Race/Ethnicity
Percent (%)
Black
43.3
Hispanic
28.9
White
18.3
Asian
4.2
Other
2.8
Unknown
2.5
Total
100%
Other Unknown Asian 2.8% 2.5% 4.2%
White 18.3%
Hispanic 28.9%
Black 43.3%
Washington Adventist Hospital | 17
Language Preference and Interpreter Services Figure 3 below shows the distribution of patients at WAH by preferred language in 2012, reflecting all patient encounters. English was the most preferred language among patients (82.6%), a slight decrease from what was reported in last year’s report (84.2%). The percentage of patients who preferred to communicate in Spanish increased from 12 percent in 2011 to 13.9 percent in 2012. The other common languages spoken at WAH include Amharic, French, Vietnamese, and Korean. Approximately 1.9 percent of WAH patients preferred to communicate in these languages. FIGURE 3. ALL PATIENT ENCOUNTERS BY PREFERRED LANGUAGE, WAH, 2012 (N=88,458)
Spanish 13.9%
Unknown 1.6% Other 1.9%
English 82.6%
All Others 0.9%
Korean 0.2% Vietnamese Amharic 0.2% 0.4% French 0.3%
Figure 4 shows the most frequently requested languages for over-the-phone interpretation at WAH. More than 9,700 calls were made during 2012, exceeding 82,000 minutes. As seen in Figure 4, the majority of the calls placed were for Spanish language interpretation, followed by Vietnamese, French, and Amharic. In addition to the languages highlighted below, calls were placed for more than 60 additional languages, including Arabic, Haitian Creole, and Mandarin (All Others, 6.9%). FIGURE 4. OVER-THE-PHONE INTERPRETER USE BY NUMBER OF CALLS, WAH, 2012
Korean 1.2% Spanish 84.4%
Other 15.6%
All Others 6.9% Amharic 1.9% French Vietnamese 2.8% 2.8%
18 | Washington Adventist Hospital
In-Depth HOSPITAL SETTING AND HEALTH INSURANCE Table 3 shows the hospital settings in which patients were seen at WAH in 2012, by race and ethnicity. For comparison, the last column of Table 3 is identical to the information given in Table 2 above. As in previous years, different patterns of utilization emerge for patients of certain racial/ethnic background. We posit that if race/ethnicity were not associated with the setting in which a patient is seen, the percentages across each row would be similar. For example, Black patients would represent approximately 43 percent of all inpatient visits, 43 percent of all outpatient visits, and 43 percent of all emergency department patients. As Table 3 shows, there are some noteworthy deviations from this expectation. For example, Hispanic patients represent 29 percent of all patient encounters at WAH, yet more than 35 percent of all emergency department visits. White patients, who account for more than 18 percent of all WAH patient encounters, only account for 14 percent of the volume in the emergency department, and 23 percent of outpatient visits. TABLE 3. ALL PATIENT ENCOUNTERS BY HOSPITAL SETTING, WAH, 2012 (N=88,458)
Race/Ethnicity
Inpatient % (N=14,882)
Outpatient % (N=32,405)
Emergency Department % (N=41,171)
ALL WAH Patients % (N=88,458)
Black
41.8
40.7
45.8
43.3
Hispanic
26.2
22.0
35.3
28.9
White
19.4
23.2
14.0
18.3
Asian
3.9
6.8
2.3
4.2
Other
4.3
3.6
1.7
2.8
Unknown
4.4
3.7
0.9
2.5
Top WAH inpatient discharge diagnoses by race/ethnicity For inpatients at WAH, diagnosis-related groups or DRGs relating to childbirth and delivery are among the top five for all patients, regardless of race/ethnicity. Excluding these DRGs, and excluding zero- and one-day stays, the two most common inpatient discharge diagnoses for Black patients at WAH were septicemia and disseminated infections (septicemia) and schizophrenia. For Hispanic patients, the most common diagnoses were major depressive disorder and septicemia; for White patients, they were bipolar disorder and septicemia; and for Asian or Pacific Islander patients, they were schizophrenia and heart failure. Figure 5 shows the hospital settings in which patients were seen at WAH in 2012, by race/ethnicity. Of all the patient encounters with Black patients, nearly half (49%) occurred in the emergency department, which is very close to what we reported last year (48%). Figure 5 also shows that Black patients accounted for 16 percent of inpatients, similar to what was reported in 2012. For both Asian and White patients, the distributions seen in Figure 5 are not significantly different from what has been observed in previous years. For both groups, emergency department patients accounted for less than 40 percent of their respective totals. For all four groups, the distributions are fairly similar to what has been observed in previous years, shifting only a few percentage points.
Washington Adventist Hospital | 19
FIGURE 5. HOSPITAL SETTING FOR ALL PATIENT ENCOUNTERS BY RACE/ETHNICITY, WAH, 2012 Black Patients (N=38,264)
Outpatient 35%
Emergency Department 49%
Outpatient 28%
Inpatient 15%
Inpatient 16%
White Patients (N=16,145)
Outpatient 47%
Hispanic Patients (N=25,578)
Asian Patients (N=3,759)
Emergency Department 26%
Emergency Department 35%
Outpatient 59% Inpatient 18%
Emergency Department 57%
Inpatient 15%
Table 4 shows health insurance coverage for all 88,458 patient encounters at WAH in 2012. Nearly 32 percent of all encounters were paid for by private insurance. However, the insurance distribution differs depending on the setting. For encounters in the emergency department, the most common insurer was Medicaid (29%). For inpatient encounters, the most common insurer was Medicare (32%), and for outpatient encounters, it was private insurance (37%). Table 4 provides context for the data presented in Figures 6, 7, and 8 below, where the primary insurance coverage for each setting is stratified by patient race/ethnicity.
20 | Washington Adventist Hospital
TABLE 4. HEALTH INSURANCE COVERAGE FOR ALL PATIENT ENCOUNTERS, WAH, 2012 (N=88,458)
WAH (All Encounters)
All All ED All Inpatient Outpatient Encounters Encounters Encounters
Self-Pay (Uninsured)
15.3
25.9
10.1
4.1
Medicaid
22.9
29.3
29.1
11.9
Private Insurance
31.6
28.9
26.6
37.4
Medicare
21.8
10.8
32.4
30.9
All Others
8.4
5.1
1.7
15.7
100%
100%
99.9%
100%
Total
Figure 6 shows the distribution of coverage for all patients treated in the emergency department at WAH in 2012, by race/ethnicity in 2012. The largest percentage of uninsured patients (self-pay) were Hispanic (over 35%). Also, Hispanic patients were least likely to be covered by Medicare in the emergency department (less than 4%). The majority of White and Asian patients were covered by private insurance (46% and 43%, respectively). FIGURE 6. HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, ALL WAH ED VOLUME, 2012 (N=41,171)
100% 90% 80% 70% 60%
All Others Medicare Private Insurance Medicaid Self-Pay (Uninsured)
50% 40% 30% 20% 10% 0%
Hispanic
White
Black
Asian
Other
Unknown
Washington Adventist Hospital | 21
Figure 7 shows health insurance coverage by race/ethnicity for inpatients at WAH during 2012. White (50.4%), Black (38%), and Asian (40%) patients were more likely to be covered by Medicare than any other insurer. For Hispanic patients, Medicaid covered more than half of inpatient hospital stays (51%). FIGURE 7.
HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, ALL WAH INPATIENT VOLUME, 2012 (N=14,882)
100% 90% 80% 70% 60%
All Others Medicare Private Insurance Medicaid Self-Pay (Uninsured)
50% 40% 30% 20% 10% 0%
Hispanic
White
Black
Asian
Other
Unknown
22 | Washington Adventist Hospital
Figure 8 shows health insurance coverage for all outpatients treated at WAH in 2012. For White, Black, and Asian patients, less than three percent of outpatients were uninsured. Slightly more than 10 percent of Hispanic patients were uninsured. Medicaid covered about 18 percent of outpatient visits for Hispanic patients, and 13 percent of visits for Black patients; this is compared to 4 percent for White patients and 8 percent for Asian patients. White (45%), Black (39%), and Asian (49%) patients were more likely to be covered by private insurance. FIGURE 8. HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, ALL WAH OUTPATIENT VOLUME, 2012 (N=32,405)
100% 90% 80% 70% 60%
All Others Medicare Private Insurance Medicaid Self-Pay (Uninsured)
50% 40% 30% 20% 10% 0%
Hispanic
White
Black
Asian
Other
Unknown
Washington Adventist Hospital | 23
Inpatient Quality Measures Table 5 shows composite scores of inpatient quality measures for WAH in 2012. A composite score of 96 percent or higher was achieved in each group. Because of overall high scores achieved within and across each of the measurement groups, differences between racial and ethnic groups were not calculated. TABLE 5. WAH INPATIENT QUALITY MEASURES - 2012
Measurement Group
Numerator
Denominator
Percentage
402
410
98.05%5
Heart Failure (HF)2
1209
1253
96.49%6
Acute Myocardial Infarction (AMI)3
2009
2013
99.80%7
Surgical Care Improvement Project (SCIP)4
5151
5228
98.53%8
Pneumonia Care (PN)
1
Measure group includes: PN-3a, PN-3b, PN-6, PN-6a, PN-6b, PN-PACS Measure group includes: HF-1, HF-2, HF-3, HF-PACS 3 Measure group includes: AMI-1, AMI-2, AMI-3, AMI-5, AMI-7a, AMI-8a, AMI-10, AMI-PACS 4 Measure group includes: SCIP-Card-2, SCIP-Inf-1a, SCIP-Inf-1b, SCIP-Inf-1c, SCIP-Inf-1d, SCIP-Inf-1e, SCIP-Inf-1f, SCIP-Inf-1g, SCIP-Inf-1h, SCIP-Inf-2a, SCIP-Inf-2b, SCIP-Inf-2c, SCIP-Inf-2d, SCIP-Inf-2e, SCIP-Inf-2f, SCIP-Inf-2g, SCIP-Inf-2h, SCIP-Inf-3a, SCIP-Inf-3b, SCIP-Inf-3c, SCIP-Inf-3d, SCIP-Inf-3e, SCIP-Inf-3f, SCIP-Inf-3g, SCIP-Inf-3h, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-9, SCIP-PACS, SCIP-VTE-1, SCIP-VTE-2 5 Percentage range across individual measures for PN: 92.31%-100% 6 Percentage range across individual measures for HF: 98.87%-100% 7 Percentage range across individual measures for AMI: 99.53%-100% 8 Percentage range across individual measures for SCIP: 91.43%-100% 1 2
In October 2013, WAH was named as a Top Performer on Key Quality Measures® by The Joint Commission, meaning they achieved at least 95 percent compliance with certain measures for 2012 performance. At WAH, only three measures were found to have a score lower than 95 percent while 33 were found to have scores of 98 percent and above, 22 of which were perfect scores. Pneumonia Care (PN) Among six quality measures, the measure with the lowest success rate was initial antibiotic selection for PN in immunocompetent non-intensive care unit (ICU) patients with a percentage of 96.88 percent. However, due to a small sample size, the 3.12 percent rate of failure represents only two patients. All remaining measures had a rate of 97.18 percent and above including two with a rate of 100 percent. Heart Failure (HF) A total of four quality measures were evaluated for HF. Among them discharge instructions were provided to 93.49 percent of patients, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blockers (ARB) for left ventricular systolic dysfunction (LVSD) were provided to 98.89 percent of patients for which it was indicated, and patient appropriateness of care compliance was found to have a rate of 94.27 percent. The fourth measure, Evaluation of left ventricular systolic (LVS) function, had a perfect completion rate of 100 percent. Acute Myocardial Infarction (AMI) Among the eight AMI measures, one was not indicated for any patients, and one—primary percutaneous coronary intervention (PCI) received within 90 minutes of hospital arrival—had a rate of 96.97 percent. Of the remaining six measures, two had a rate of 99.51 percent and above, while the other four had a rate of 100 percent.
24 | Washington Adventist Hospital
Surgical Care Improvement Project (SCIP) Among the four groups of inpatient quality measures, SCIP had the largest number of measures with a total of 32. Twenty-one of these measures had a score of at least 98.5 percent while 15 had a perfect score of 100 percent. The measure with the lowest score of 94.53 percent was patient appropriateness of care compliance.
Washington Adventist Hospital
Washington Adventist Hospital | 25
Hospital Readmissions Table 6 below shows the all-cause 30-day readmission percentages for patients at WAH, during 2012. Using the methodology described, the overall readmission percentage for WAH was 7.6 percent. There were 969 readmissions, and 11,820 discharges. Readmissions for Black patients were the highest of all racial/ethnic groups (approximately 10.7%). The percentage for White patients was slightly lower (9.5%). Readmissions for all other racial/ethnic groups were lower than the hospital average (6.9% for Asian patients and 5.0% for Hispanic patients). TABLE 6. ALL CAUSE 30-DAY READMISSIONS BY PATIENT RACE/ETHNICITY, WAH, 2012
Race/Ethnicity
Readmissions
Black
10.7
White
9.5
Asian
6.9
Hispanic
5.0
Other
4.4
Unknown
2.3
Total
8.2%
26 | Washington Adventist Hospital
Patient Experience
Table 7 below shows the percent of WAH inpatients who responded positively to selected HCAHPS questions (top box scores) by race/ethnicity, in 2012. Hispanics and Blacks discharged from WAH responded more positively to patient experience items than White patients for most measures. However, Asians were less likely than other minority groups to report positive experiences compared with Whites. Overall ratings of the hospital and likelihood to recommend were more positive for Hispanics and Blacks compared with White and Asian patients. Also, satisfaction with communication with doctors and nurses was higher for non-White patients compared to Whites. Asian patients were less likely to respond positively to items about staff courtesy or communication. Most survey respondents seemed satisfied with staff courtesy and written discharge instructions, indicating continued commitment to providing excellent care. Specifically, WAH has implemented nursing campaigns to encourage consistent and meaningful patient interactions, which is reflected in more positive ratings in this year’s report. Nurses and patient care technicians are required to check in on every patient on an hourly basis (i.e., hourly rounding). Daily rounding is the responsibility of nursing leadership (e.g., charge nurses and nurse managers). In addition, WAH’s leadership is required to round on at least one patient a week in their assigned area at the hospital. Regular patient rounding is productive and can shed light on patient concerns or issues such as pain management and needs for personal assistance such as help getting up from bed. In 2012, compliance for daily nurse rounding and logging rounding information was 93 percent at WAH. TABLE 7. SELECTED TOP BOX RESPONSES TO HCAHPS QUESTIONS, BY RACE/ETHNICITY**, WAH, 2012 (IN PERCENTS)
All WAH
White Patients
Black Patients
Asian Patients
Hispanic Patients*
HSTM
Likely to recommend
70.1
64
73.7
61
73.6
74.2
Overall rating of hospital
62.8
57.4
68
52.3
64.8
70.6
Courtesy of doctors
82.5
78
87.1
67.4
85.7
87.9
Doctors listen carefully
76.7
68.1
82.3
71.4
80.4
80.8
Clear communication by doctors
73.4
64.9
79.6
58.1
80.4
77.3
Courtesy of nurses
84.2
79.3
87.8
80
83
86.3
Nurses listen carefully
74.3
65.4
79.4
69
83.6
77.9
Clear communication by nurses
73.2
64.5
78.1
66.7
76.8
76.1
Talking about help after discharge
80.3
81.5
81.9
73.7
81.6
83.3
Providing written discharge instructions
85.6
88.5
85.5
78.6
87.8
88.3
* Percentages averaged across all persons self-identifying as Hispanic or Latino. Includes Puerto Ricans, Mexicans, Mexican-Americans, Chicanos, Cubans, and others. ** Race and ethnicity are not mutually exclusive in this table. Therefore, if a patient identified himself as both Black and Hispanic, his responses are included in both columns.
Washington Adventist Hospital | 27
Table 8 below shows the percent of WAH inpatients who responded positively to selected HCAHPS questions (top box scores), stratified by the patient’s level of education. Results reveal a decrease in satisfaction scores as level of education increases. Comparisons between individuals who completed more than four years of college and those who did not graduate from high school reveal a greater than 15 percent difference in the “likelihood to recommend” measure for respondents. Because a significant proportion of residents in Maryland (e.g., Montgomery County) and the D.C. metropolitan area are highly educated, it may be important to understand the relationship between education level and satisfaction with hospital care.28,29 In the future, efforts that address differences in patient experience between patients with different levels of education may be necessary to reach our performance goal of achieving top quartile patient experience. TABLE 8. SELECTED TOP BOX RESPONSES TO HCAHPS QUESTIONS BY EDUCATION LEVEL, WAH, 2012 (IN PERCENTS)
Some More Graduated Graduated college than 4 from from high or earned years of 4-year earned a a 2-year college college GED degree
Some high Completed school the 8th but did grade or not less graduate
Likely to recommend
73.6
80.2
87.4
85.9
89.9
100.0
Overall rating of hospital
60.0
73.5
77.9
75.2
80.0
83.3
Courtesy of doctors
65.1
71.9
73.1
75.5
71.3
91.7
Doctors listen carefully
78.1
80.5
81.7
83.5
86.3
88.5
Clear communication by doctors
66.0
78.6
76.4
78.2
81.5
96.2
Courtesy of nurses
62.0
77.0
73.3
71.5
82.7
88.5
Nurses listen carefully
78.9
77.9
87.0
74.5
86.5
82.6
Clear communication by nurses
91.0
82.2
87.9
84.8
83.1
79.2
Talking about help after discharge
51.3
62.8
63.6
64.5
76.3
65.4
Providing written discharge instructions
62.2
73.9
71.4
69.8
75.6
78.3
Shady Grove Adventist Hospital
Shady Grove Adventist Hospital | 29
Snapshot of Diversity Table 9 and Figure 9 below show the distribution of all unique patients at Shady Grove Adventist Hospital (SGAH) in 2012, by race and ethnicity. SGAH patients include those treated at the main hospital in Rockville, as well as at the Shady Grove Adventist Emergency Center in Germantown, Maryland. With the full implementation of our electronic medical record platform in 2012, we are able distinguish between patients who actively declined to report their race and/or ethnicity from those patients for whom the information is unknown for any other reason, as seen below in Tables 9 and 10 and Figures 9 and 10. Throughout the remainder of the report, the SGAH patients who declined to report their race/ethnicity are included in the ‘Unknown’ category. Table 9 and Figure 9 show that White patients accounted for nearly 38 percent of all unique patients seen at SGAH in 2012. Hispanic patients accounted for 24 percent of all patients, while Black patients accounted for 13 percent and Asian patients for 8 percent. (Note: See “About the 2013 Health Equity Report” for details on methodology, sources, limitations, inclusions/exclusions, missing data, and other information about the data reported here.) TABLE 9 AND FIGURE 9. ALL UNIQUE PATIENTS BY RACE/ETHNICITY, SGAH, 2012 (N=121,729)
Race/Ethnicity
Percent (%)
White
37.7
Hispanic
24.4
Black
13.4
Asian
8.0
Other
4.2
Declined
1.2
Unknown
11.1
Total
100%
Declined 1.2% Unknown Other 11.1% 4.2% Asian 8.0% Black 13.4%
White 37.7%
Hispanic 24.4%
Table 10 and Figure 10 below show the racial/ethnic distribution for all patient encounters at SGAH in 2012. In the table and figure below, the same patients may be included multiple times. The distribution is very similar to the patient distribution seen in Table 9 and Figure 9 above. TABLE 10 AND FIGURE 10. ALL PATIENT ENCOUNTERS BY RACE/ETHNICITY, SGAH, 2012 (N=164,049)
Race/Ethnicity
Percent (%)
White
37.1
Hispanic
25.9
Black
14.6
Asian
7.4
Other
4.1
Declined
1.0
Unknown
9.9
Total
100%
Black 15% Hispanic 26%
Asian 7%
Unknown 10% White 37%
Other 4% Declined 1%
30 | Shady Grove Adventist Hospital
Language Preference and Interpreter Services Figure 11 shows the distribution of patients by preferred language at SGAH in 2012, reflecting all patient encounters. English was the most preferred language among patients (90%), similar to what was reported in last year’s report. The percentage of patients who preferred to communicate in Spanish increased slightly, from 4 percent in 2011 to 5 percent in 2012. The other preferred languages at SGAH include Chinese (both Mandarin and Cantonese), Korean, French, and Farsi. Just over two percent of SGAH patients preferred to communicate in these languages. FIGURE 11. ALL PATIENT ENCOUNTERS BY PREFERRED LANGUAGE, SGAH, 2012 (N=164,049) Spanish 5.0%
Russian 0.1%
Unknown 4.0% English 88.7%
Other 2.4%
All Others 1.0%
Farsi 0.2%
French 0.2% Korean 0.3%
Chinese 0.6%
Figure 12 shows the languages most frequently requested for interpretation by phone at SGAH. More than 12,000 calls were placed, exceeding 113,000 minutes. As seen in Figure 12, the majority of the calls were for Spanish language interpretation, followed by Mandarin, Korean, and Russian. In addition to the languages highlighted below, calls were placed for more than 70 additional languages, including Arabic, Bengali, and Hindi (All Others, 5.9%). FIGURE 12. OVER-THE-PHONE INTERPRETER USE BY NUMBER OF CALLS, SGAH, 2012 Mandarin 8.5% Korean 4.4% Russian 4.2%
Spanish 68.5%
Other 14.4%
Farsi 1.9%
All Others 5.9%
Vietnamese 2.0% Cantonese 2.3%
French 2.3%
Shady Grove Adventist Hospital | 31
In-Depth HOSPITAL SETTING AND HEALTH INSURANCE Table 11 shows the hospital settings where patients were seen at SGAH, and the Shady Grove Adventist Emergency Center in 2012, by race/ethnicity. The last column of Table 11 reflects the same information in Table 10 above. As in previous years, we observe different patterns of hospital utilization by patients from different racial/ethnic groups. White patients, who accounted for 37 percent of all patient volume, made up 45 percent of inpatient visits, and only 34 percent of emergency department visits. Hispanic patients, who accounted for 26 percent of total patient volume, accounted for about 30 percent of emergency department volume, and only 21 percent of inpatient volume. Black patients utilized the emergency department at higher rates than Asian patients, who were more likely to use inpatient and outpatient services. TABLE 11. ALL PATIENT ENCOUNTERS BY HOSPITAL SETTING, SGAH, 2012 (N=164,049)
Race/Ethnicity
Inpatient % (N=26,111)
Outpatient % (N=46,848)
Emergency Department % (N=91,090)
ALL SGAH Patients % (N=164,049)
White
45.3
38.6
34.0
37.1
Hispanic
20.9
21.2
29.7
25.9
Black
12.6
11.1
17.0
14.6
Asian
10.9
10.0
5.1
7.4
Other
4.0
3.8
4.2
4.1
Unknown
6.2
15.3
10.0
10.9
Top SGAH hospital inpatient discharge diagnoses by race/ethnicity For inpatients at SGAH, diagnostic-related groups (DRGs) relating to childbirth and delivery are among the top five for all patients, regardless of race/ethnicity. Excluding these DRGs, and excluding zeroand one-day stays, the two most common inpatient discharge diagnoses for White patients at SGAH were septicemia and pneumonia. For Hispanic patients, the two most common were kidney/urinary tract infections and pneumonia. For Black patients, the most common diagnoses were heart failure and sickle cell anemia crises, and for Asian patients, they were pneumonia and septicemia. Figure 13 shows the hospital settings in which patients were seen at SGAH in 2012, by race/ethnicity. For both Black and Hispanic patients, the majority of encounters occurred in the emergency department; for both groups, emergency department visits accounted for more 60 percent of all visits. In comparison, emergency department visits accounted for approximately half of all visits for White patients. For Asian patients, emergency department visits accounted for less than 40 percent of all visits. Again, for all four groups, the distributions seen in Figure 13 are very similar to the data presented in last year’s report.
32 | Shady Grove Adventist Hospital
FIGURE 13. HOSPITAL SETTING FOR ALL PATIENT ENCOUNTERS BY RACE/ETHNICITY, SGAH, 2012 Black Patients (N=23,960)
Hispanic Patients (N=42,465)
Outpatient 22% Inpatient 14%
Outpatient 23% Emergency Department 64%
Emergency Department 64%
Inpatient 13%
White Patients (N=60,868)
Asian Patients (N=12,218)
Outpatient 30%
Emergency Department 39%
Outpatient 38%
Emergency Department 51%
Inpatient 19%
Inpatient 23%
Table 12 shows the primary health insurance coverage for all 164,049 patient encounters at SGAH in 2012. Nearly 57 percent of all encounters were paid for by private insurance. Private insurance was the dominant insurer for all settings, covering the majority of inpatient (57%) and outpatient (71%) encounters. In the emergency department, private insurance covered just less than half of the encounters. Table 12 provides context for the data presented in Figures 14, 15, and 16, where the primary insurance coverage in each setting is stratified by patient race/ethnicity. TABLE 12. HEALTH INSURANCE COVERAGE FOR ALL PATIENT ENCOUNTERS, SGAH, 2012 (N=164,049)
All SGAH (All All ED All Inpatient Outpatient Encounters) Encounters Encounters Encounters Self-Pay (Uninsured)
12.6
16.8
6.7
7.8
Medicaid
22.2
26.7
20.4
14.5
Private Insurance
57.2
49.8
57.1
71.4
Medicare
6.0
3.9
15.3
4.9
All Others
2.0
2.7
0.5
1.4
100%
99.9%
99.9%
100%
Total
Shady Grove Adventist Hospital | 33
Figure 14 shows the distribution of coverage for all patients treated in the emergency department at SGAH in 2012, by race/ethnicity. Hispanic (20%) and Black patients (19%) were more likely to be uninsured compared to White or Asian patients (less than 11% for both groups). It is also noteworthy that of all the White patients seen in the emergency department, nearly 68 percent were covered by private insurance. The private insurance coverage for Asian patients was about 66 percent. In comparison, the private insurance coverage for Black and Asian patients was approximately 37 percent and 35 percent, respectively. Similarly, Medicaid coverage was similar for Black and Hispanic patients, at about 38 percent each; however, it was about 14 percent for White patients and 17 percent for Asian patients. FIGURE 14. HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, ALL SGAH ED VOLUME, 2012 (N=91,090)
100% 90% 80% 70% 60%
All Others Medicare Private Insurance Medicaid Self-Pay (Uninsured)
50% 40% 30% 20% 10% 0%
Hispanic
White
Black
Asian
Other
Unknown
34 | Shady Grove Adventist Hospital
Figure 15 shows health insurance coverage by race/ethnicity, for all inpatients at SGAH during 2012. Hispanic, White, Black, and Asian patients were more likely to be covered by private insurance. Private insurance coverage was higher than 65 percent for both White and Asian patients, and just about 42 percent for both Hispanic and Black patients. Medicaid coverage was approximately 35 percent for both Hispanic and Black patients, about 18 percent for Asian patients, and about 9 percent for White patients. Medicare coverage was highest for White patients (19%), followed by Black patients (13%), Asian patients (12%), and Hispanic patients (9%). Hispanic patients were most likely to be uninsured (over 11%). FIGURE 15. HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, ALL SGAH INPATIENT VOLUME, 2012 (N=26,111)
100% 90% 80% 70% 60%
All Others Medicare Private Insurance Medicaid Self-Pay (Uninsured)
50% 40% 30% 20% 10% 0%
Hispanic
White
Black
Asian
Other
Unknown
Shady Grove Adventist Hospital | 35
Figure 16 shows the health insurance coverage for all outpatients treated at SGAH in 2012. Similar to inpatients, most outpatient visits were covered by private insurance for each group of patients. Private insurance coverage ranged from 59 percent for Black patients, up to 82 percent for White patients. Medicaid coverage was highest for Black patients (about 29%). FIGURE 16. HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, ALL SGAH OUTPATIENT VOLUME, 2012 (N=46,848)
100% 90% 80% 70% 60%
All Others Medicare Private Insurance Medicaid Self-Pay (Uninsured)
50% 40% 30% 20% 10% 0%
Hispanic
White
Black
Asian
Other
Unknown
36 | Shady Grove Adventist Hospital
Inpatient Quality Measures Table 13 shows composite scores of inpatient quality measures for SGAH for 2012. A composite score of 96 percent or higher was achieved in each group. Because of overall high scores achieved within and across each of the measurement groups, differences between racial and ethnic groups were not calculated. TABLE 13. SGAH INPATIENT QUALITY MEASURES - 2012
Measurement Group
Numerator
Denominator
Percentage
598
618
96.76%5
Heart Failure (HF)2
1093
1100
99.36%6
Acute Myocardial Infarction (AMI)3
1290
1292
99.85%7
Surgical Care Improvement Project (SCIP)4
8653
8752
98.87%8
Pneumonia Care (PN)
1
Measure group includes: PN-3a, PN-3b, PN-6, PN-6a, PN-6b, PN-PACS Measure group includes: HF-1, HF-2, HF-3, HF-PACS 3 Measure group includes: AMI-1, AMI-2, AMI-3, AMI-5, AMI-7a, AMI-8a, AMI-10, AMI-PACS 4 Measure group includes: SCIP-Card-2, SCIP-Inf-1a, SCIP-Inf-1b, SCIP-Inf-1c, SCIP-Inf-1d, SCIP-Inf-1e, SCIP-Inf-1f, SCIP-Inf-1g, SCIP-Inf-1h, SCIP-Inf-2a, SCIP-Inf-2b, SCIP-Inf-2c, SCIP-Inf-2d, SCIP-Inf-2e, SCIP-Inf-2f, SCIP-Inf-2g, SCIP-Inf-2h, SCIP-Inf-3a, SCIP-Inf-3b, SCIP-Inf-3c, SCIP-Inf-3d, SCIP-Inf-3e, SCIP-Inf-3f, SCIP-Inf-3g, SCIP-Inf-3h, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-9, SCIP-PACS, SCIP-VTE-1, SCIPVTE-2 5 Percentage range across individual measures for PN: 92.31%-100% 6 Percentage range across individual measures for HF: 98.87%-100% 7 Percentage range across individual measures for AMI: 99.53%-100% 8 Percentage range across individual measures for SCIP: 91.43%-100% 1 2
In October 2013, SGAH was named as a Top Performer on Key Quality Measures® by The Joint Commission, meaning they achieved at least 95 percent compliance with certain measures for 2012 performance. At SGAH, only two measures were found to have a score lower than 95 percent while 35 were found to have scores of 98 percent and above, 13 of which were perfect scores. Pneumonia Care (PN) Among six quality measures, the one with the lowest score was blood culture on arrival for intensive care unit (ICU) patients with a score of 92.3 percent. However, due to a small sample size, the remaining 7.7 percent represents only two patients. Measures of initial antibiotic selection in immunocompetent patients were found to have a score of 96.15 percent among 156 non-ICU patients and 100 percent for seven ICU patients. Heart Failure (HF) A total of four quality measures were evaluated for HF. Among them discharge instructions were provided to 98.87 percent of patients, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blockers (ARB) for left ventricular systolic dysfunction (LVSD) scored 99.2 percent and patient appropriateness of care compliance scored 99.14 percent. The fourth measure, Evaluation of left ventricular systolic (LVS) function, had a perfect score of 100 percent. Acute Myocardial Infarction (AMI) Among the eight AMI measures, one was not indicated for any patients, and two—aspirin at arrival and patient appropriateness of care compliance—had a score of 99.53 percent and 99.63 percent, respectively. The remaining five measures had a perfect score of 100 percent.
Shady Grove Adventist Hospital | 37
Surgical Care Improvement Project (SCIP) Among the four groups of inpatient quality measures, SCIP had the largest number of measures with a total of 32. Seven of these measures were not applicable to the patients seen. Twenty-one measures had a score of at least 98.5 percent while six had a perfect score of 100 percent. Two of the measures, discontinuation of prophylactic antibiotics within 24 hours after hysterectomy and beta blocker given during the perioperative period for those on beta blocker therapy preadmission, had the lowest scores of 91.43 percent and 96.51 percent, respectively.
Shady Grove Adventist Hospital
38 | Shady Grove Adventist Hospital
Hospital Readmissions Table 14 below shows the all-cause 30-day readmission percentages for patients at SGAH, during 2012. The overall readmission percentage for SGAH was 6.2 percent. There were 1,300 readmissions, and 20,982 discharges. Readmissions for Black patients were the highest of all racial/ethnic groups (8.0%). The percentage for White patients was lower (7.2%). Readmissions for all other racial/ethnic groups were lower than the hospital average (4.2% for Asian patients and 4.7% for Hispanic patients). TABLE 14. ALL CAUSE 30-DAY READMISSIONS BY PATIENT RACE/ETHNICITY, SGAH, 2012
Race/Ethnicity
Readmissions
Black
8.0
White
7.2
Asian
4.2
Hispanic
4.7
Other
3.9
Unknown
-
Total
6.2%
Shady Grove Adventist Hospital | 39
Patient Experience Table 15 below shows the percent of SGAH inpatients who responded positively to selected HCAHPS questions (top box scores) by race/ethnicity in 2012. Hispanics, Asians, and Blacks discharged from SGAH were more likely to respond positively to the patient experience items than White patients for most measures. Overall ratings of the hospital were more positive for non-White patients (particularly Hispanics) compared to White patients. More Hispanics and Asians were likely to recommend the hospital than were White patients. Also, compared to Whites, non-White patients were more likely to be satisfied with communication with doctors and nurses. These findings are similar to those reported in several studies of racial/ethnic differences in patients’ experience of care.30,31 Survey respondents across racial groups seemed particularly satisfied with staff courtesy and written discharge instructions, demonstrating commitment to ensuring continuity of care for patients. Nursing communication was viewed more favorably among patients responding to this year’s survey compared with last year’s responses. TABLE 15. SELECTED TOP BOX RESPONSES TO HCAHPS QUESTIONS, BY RACE/ETHNICITY**, SGAH, 2012 (IN PERCENTS)
All SGAH Patients
White Patients
Black Patients
Asian Patients
Hispanic Patients*
HSTM
Likely to recommend
64.1
59.7
65.7
74.2
78.3
74.2
Overall rating of hospital
56.6
54.6
59.9
51.9
71.8
70.6
Courtesy of doctors
81.7
78.4
84.2
80.8
85.9
87.9
Doctors listen carefully
73.8
69.4
74.9
78.8
83.3
80.8
Clear communication by doctors
70.8
66.6
73.2
77.1
76.4
77.3
Courtesy of nurses
78.5
73.9
81
76.4
84.3
86.3
Nurses listen carefully
69
62.4
73.9
75.6
65.3
77.9
Clear communication by nurses
68.2
63.9
73.2
70.2
69.4
76.1
Talking about help after discharge
79.2
77.3
76.2
81.7
75.4
83.3
Providing written discharge instructions
90.6
89.9
90.3
89.8
95.3
88.3
* Percentages averaged across all persons self-identifying as Hispanic or Latino. Includes Puerto Ricans, Mexicans, Mexican-Americans, Chicanos, Cubans, and others. ** Race and ethnicity are not mutually exclusive in this table. Therefore, if a patient identified himself as both Black and Hispanic, his responses are included in both columns.
40 | Shady Grove Adventist Hospital
Table 16 below shows the percent of SGAH inpatients who responded positively to the selected HCAHPS questions (top box scores), stratified by the patient’s level of education. Results reveal a decrease in satisfaction scores as level of education increases. Comparisons between individuals who completed more than four years of college and those who did not graduate from high school reveal a greater than 10 percent difference in the “likelihood to recommend” measure for respondents. Because a significant proportion of residents in Maryland (e.g., Montgomery County) and the D.C. metropolitan area are highly educated, it may be important to understand the relationship between education level and satisfaction with hospital care.32,33 In the future, efforts that address differences in patient experience between patients with different levels of education may be necessary to reach our performance goal of achieving top quartile patient experience. TABLE 16. SELECTED TOP BOX RESPONSES TO HCAHPS QUESTIONS BY EDUCATION LEVEL, SGAH, 2012 (IN PERCENTS)
Some Graduated More than college from 4 years of or earned 4-year college a 2-year college degree
Some Graduated high Completed from high school the 8th school or but did grade or earned a not less GED graduate
Likely to recommend
74.6
70.5
77.1
83.0
85.2
78.6
Overall rating of hospital
67.6
56.5
64.3
78.1
80.0
66.7
Courtesy of doctors
62.4
61.8
67.2
72.2
81.8
86.7
Doctors listen carefully
79.1
78.1
82.5
83.7
88.9
73.3
Clear communication by doctors
71.5
69.0
71.9
76.3
83.3
80.0
Courtesy of nurses
69.0
68.4
68.7
73.2
77.8
73.3
Nurses listen carefully
79.9
74.8
77.7
80.5
80.0
66.7
Clear communication by nurses
91.5
92.2
89.4
88.3
88.9
78.6
Talking about help after discharge
53.1
50.5
56.4
62.3
81.8
73.3
Providing written discharge instructions
63.7
56.5
63.3
67.3
78.4%
78.6
Shady Grove Adventist Hospital | 41
Office of Minority Health CLAS Standards In April 2013, the Office of Minority Health of the U.S. Department of Health and Human Services released the Enhanced Culturally and Linguistically Appropriate Services (CLAS) Standards to improve quality, eliminate health disparities, and advance health equity. These standards, originally developed in 2000, were updated to reflect growing diversity in the nation and to improve understanding and use of culturally appropriate care at healthcare organizations. The revised CLAS standards fall under four categories: (1) principal standard; (2) governance, leadership, and workforce; (3) communication and language assistance; and (4) engagement, continuous improvement and accountability. PRINCIPAL STANDARD 1) Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. Governance, Leadership and Workforce 2) Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices and allocated resources. 3) Recruit, promote and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area. 4) Educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance 5) Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6) Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7) Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8) Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement, Continuous Improvement and Accountability 9) Establish culturally and linguistically appropriate goals, policies and management accountability, and infuse them throughout the organizations’ planning and operations. 10) Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities. 11) Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12) Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13) Partner with the community to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness. 14) Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints. 15) Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents and the general public. For more information about the enhanced CLAS Standards, visit http://minorityhealth.hhs.gov/templates/ browse.aspx?lvl=2&lvlID=15.
Adventist Behavioral Health
Adventist Behavioral Health | 43
SPOTLIGHT ON MENTAL HEALTH Mental health includes emotional, psychological, and social well-being, dealing with how we think and how we feel.34 Mental disorders are health conditions that are characterized by alterations in normal cognitive function resulting in a change in mood, and/or behavior associated with distress and/or impaired functioning. In any given year, one in four adults suffers from a mental health illness in the United States.35 One in seventeen live with a serious mental illness such as schizophrenia, major depression or bipolar disorder. Among children, the rates are slightly higher; about one in 10 is diagnosed with a serious mental or emotional disorder, the most common of which is attention deficit hyperactivity disorder (ADHD). Although an estimated 57.5 million adults and 9.6 million children suffer from mental disorders each year in the United States, only 36.2 million Americans account for the $57.5 billion spent annually on mental health services indicating that many individuals may not be receiving the care they need.36 In 2012, approximately 60 percent of adults, and nearly half of youth ages 8 to 15 with a mental illness received no mental health services.37 The impact of mental illness is far reaching: nearly $193.2 billion in earnings is lost annually, mood disorders such as depression are the third leading cause of hospitalization for youth and adults ages 18 to 44, and suicide is the 10th leading cause of death in the United States. Among Maryland’s 5.6 million residents, an estimated 175,000 adults and 62,000 children live with a serious mental health disorder.38 However, the proportion of individuals suffering from mental health illness far outweighs the services available. Maryland’s public mental health system provides services to only 19 percent of adults who live with a serious mental illness. Untreated mental illness can have deadly consequences. For example, in 2006, 495 Maryland residents died by suicide, which is nearly always the result of untreated or under-treated mental illness. In Montgomery County, one in ten residents have been diagnosed with an anxiety disorder, a general term used to describe a condition with excessive and unrealistic worrying, anxiety, and persistent fear.39,40 About 80 percent of Montgomery County residents report good mental health (i.e., two or fewer days of poor mental health a month), higher than the state average of 77 percent. The level of substance abuse in Montgomery County continues to increase yearly and aligns with the state average. In Wicomico County, 79 percent of residents report feelings of good mental health.41 MENTAL HEALTH DISPARITIES BY RACE/ETHNICITY Despite the fact that mental illness is prevalent among racial and ethnic minorities as it is among Whites, minorities have less access to and are less likely to use mental health services, resulting in a higher proportion of individuals with unmet mental health needs. Minority groups are also less likely to seek out mental health counseling and treatment than Whites, decreasing their chances of having positive health outcomes. Many factors contribute to one’s overall mental health status, including environment, financial stability, gender, and race/ethnicity. People are classified as having a serious mental illness if they currently or at any time in the past year had a diagnosable mental, behavioral, or emotional disorder resulting in substantial impairment in carrying out major life activities.43 When stratified by race and ethnicity, 5.3 percent of Whites, 3.7 percent of Blacks, and 4 percent of Hispanic/Latinos suffer from serious mental illnesses. These rates of serious mental illness often mirror high rates of illicit drug use and abuse and act as a risk factor for suicide. In regards to substance abuse treatment, 15 percent of Blacks who needed treatment received it, compared to only 7 percent of Hispanics and 2 percent of Asians.44 These statistics could be due to barriers such as social stigmas, cost of care, language, mistrust of physicians, or poor access to mental health services. After ageadjustment, Blacks have a suicide rate of 5 per 100,000 individuals which is lower than Hispanics (6 per 100,000) and nearly half the rate of Whites (12.5 per 100,000).45 The suicide rate for Blacks is 60 percent lower than that of non-Hispanic Whites; however the death rate for Black men was almost four times that for Black women in 2009. Asian women have been found to have the highest suicide rates of all women over the age of 65. Among Hispanic girls of high school age, suicide attempts were 70 percent higher than
44 | Adventist Behavioral Health
for White girls of the same age in 2011.46 Blacks have been found to be over-diagnosed with schizophrenia and under-diagnosed with mood disorders. While Blacks are less likely to suffer from major depressive disorders, they are more likely to rate their depression as severe and disabling.47 Blacks are also less likely than Whites to receive mental health treatment at higher income and education levels while Hispanics are less likely to receive mental health treatment than Whites at every income and education level.48 According to the Substance Abuse and Mental Health Services Administration, poor individuals experience high rates of mental health treatment (15.8%) compared to those who were near poor (12.8%) or those who were not poor (13%), underscoring the correlation between poverty and poor mental health.49 In 2008, the state of Maryland spent $899 million dollars for mental health services. These expenditures allocated to bridge the gap in mental health disparities have risen each year, but have continued to fall short of meeting the needs of target populations. Maryland’s Behavioral Risk Factor Surveillance System showed that minority groups in the state under-utilize mental health services. In every age group, nonHispanic Whites are more likely to see a provider for a mental health problem than non-Hispanic Blacks, despite having an equal burden. Similar to national rates, Maryland also reports similar statistics in regards to suicide rates. For intentional self-harm, 11 percent of Whites compared to 5.3 percent of Blacks and 9.1 percent of the overall population report intentionally harming themselves.50 In Montgomery County, White Medicaid recipients were more likely to receive inpatient, outpatient, and/or professional services for episodic mood disorders (39%) than Blacks (35%), Hispanics (13%), or Asians (5.8%).51 Black Medicaid recipients in the county were more likely to receive support for attention deficit disorder, attention deficit hyperactivity disorder, and substance abuse than any other racial /ethnic group. In regards to substance abuse, 14.3 percent of the county residents had reported levels of binge drinking; only Whites exceeded the average rate. Blacks were more likely to report being current smokers than adults of other racial/ethnic groups in the county. In Wicomico County, non-Hispanic Whites were more likely (81.8%) to report positive feelings of mental health than non-Hispanic Blacks (72.4%).52 These rates differ from national statistics. This could be the result of changes in social and environmental support experienced by different sub-groups. Blacks in Dorchester County experienced the highest rates of emergency department visits because of behavioral health issues (15,138 per 100,000 individuals) compared with Hispanics (3,737 visits per 100,000) and Whites (9,789 visits per 100,000). ADVENTIST BEHAVIORAL HEALTH Adventist Behavioral Health (ABH) is the most comprehensive provider of behavioral health services in the National Capital area providing a wide-ranging spectrum of services and treatment options. With locations in Montgomery County in Maryland and on the Eastern Shore (ABH-Eastern Shore) of Maryland, ABH offers a broad range of services such as acute care, residential treatment, special education and general education programs, chemical dependency programs, partial hospitalization programs, intensive outpatient services, and community-based residential services. In addition to a free-standing facility in Rockville, services are offered at Washington Adventist Hospital in Takoma Park. Services are provided in a variety of settings including hospital-based programs, residential treatment centers, school programs, residential group homes, outpatient services and community-based services. ABH’s inpatient treatment programs provide treatment for a range of mental and behavioral health illnesses, including schizophrenia, mood disorder, post-traumatic stress disorder, suicide ideations, bipolar disorder, and depression. The following tables and figures present more detailed information on patients treated at both the Montgomery County and Dorchester County campuses of ABH in 2012.
Adventist Behavioral Health | 45
Snapshot of Diversity This year, patient data from Adventist Behavioral Health (ABH) is included in the Health Equity Report for the first time. ABH has facilities in Montgomery County, serving patients in Montgomery, Prince George’s, and Frederick counties (ABH-Rockville). Additionally, ABH-Eastern Shore primarily serves the pediatric population of Dorchester and Wicomico counties. Due to the very different populations treated at each location, most of the data for ABH are presented by location. A total of 3,121 unique patients were seen at ABH-Rockville in 2012. Table 17 and Figure 17 below show the distribution of patients by race/ethnicity. Almost 39 percent of the patients were White, and approximately 23 percent of the patients were Black. A relatively small percentage of patients identified as Hispanic (7%) or Asian (2%). In comparison, for a relatively large number of patients (collectively, almost 30%) race was classified as ‘Other’ or ‘Unknown’. (Note: See “About the 2013 Health Equity Report” for details on methodology, sources, limitations, inclusions/exclusions, missing data, and other information about the data reported here.) TABLE 17 AND FIGURE 17. ALL UNIQUE PATIENTS BY RACE/ETHNICITY, ABH-ROCKVILLE, 2012 (N=3,121)
Race/Ethnicity
Percent (%)
White
38.6
Black
22.9
Hispanic
6.8
Asian
2.3
Other
12.5
Unknown
16.9
Total
100%
Unknown 16.9% White 38.6%
Other 12.5% Asian 2.3%
Hispanic 6.8%
Black 22.9%
In 2012, a total of 287 unique patients were seen at ABH-Eastern Shore. ABH-Eastern Shore treats children and adolescents only. Table 18 and Figure 18 show the racial/ethnic breakdown of the unique patients treated at ABH-Eastern Shore in 2012. Reflecting the population of the Eastern Shore, nearly all of the patients treated at ABH identified as either White (66%) or Black (25%). TABLE 18 AND FIGURE 18. ALL UNIQUE PATIENTS BY RACE/ETHNICITY, ABH-EASTERN SHORE, 2012 (N=287)
Race/Ethnicity
Percent (%)
White
66.2
Black
25.1
Hispanic
3.5
Asian
0.7
Other
4.5
Total
100%
Asian Other 0.7% 4.5% Hispanic 3.5%
Black 25.1%
White 66.2%
46 | Adventist Behavioral Health
In addition to the patients seen at ABH-Rockville and ABH-Eastern Shore, there were 1,688 unique patients classified in their medical record as either a walk-in or call-in, and not associated with either location. Including these patients, there was a combined total of 7,635 patient encounters for all of ABH (multiple visits at Rockville and Eastern Shore locations, and call-ins/walk-ins) in 2012. The racial/ethnic composition of ABH patients, representing all encounters, is presented in Table 19 and Figure 19 below. As most of the ABH patient volume can be attributed to patients treated at the Rockville location, the racial/ethnic composition seen in Table 19 and Figure 19 is fairly similar to the data seen in Table 17 and Figure 17. TABLE 19 AND FIGURE 19. ALL PATIENT ENCOUNTERS BY RACE/ETHNICITY, ABH 2012 (N=7,635)
Race/Ethnicity
Percent (%)
White
37.6
Black
21.8
Hispanic
6.3
Asian
1.8
Other
10.8
Unknown
21.8
Total
100.1%*
Unknown 22%
White 37%
Other 11% Asian 2%
Hispanic 6%
Black 22%
* Due to rounding
Adventist Behavioral Health - Rockville Campus
Adventist Behavioral Health | 47
Interpreter Services Figure 20 shows the most frequently requested languages for interpretation by phone at ABH-Rockville. ABH-Rockville placed more than 240 calls, exceeding 4,300 minutes. The vast majority of the calls were for Spanish language interpretation, followed by Korean, Mandarin, and Farsi. In addition to the languages highlighted below, calls were placed for four additional languages: Urdu, Tibetan, Vietnamese, and German (All Others, 2.0%). For ABH-Eastern Shore, 14 calls were made during 2012, exceeding 200 minutes. All of the calls placed by ABH-Eastern Shore were for Spanish interpretation. FIGURE 20. OVER-THE-PHONE INTERPRETER USE BY NUMBER OF CALLS, ABH-ROCKVILLE, 2012
Farsi 1.2% Spanish 92.0%
Other 8.0%
Mandarin 2.0%
All Others 2.0%
Korean 2.8%
Adventist Behavioral Health - Eastern Shore Campus
48 | Adventist Behavioral Health
In-Depth HEALTH INSURANCE AND PRIMARY DIAGNOSIS Figure 21 below shows health insurance coverage by race/ethnicity for all unique patients seen at ABHRockville, in 2012. Hispanic, Black, and Asian patients were covered primarily by Medicaid. However, the majority of White patients were covered by private insurance. Interestingly, nearly all of the patients for whom race/ethnicity was unknown had no insurance coverage. FIGURE 21. HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, FOR ALL UNIQUE PATIENTS, ABH-ROCKVILLE, 2012 (N=3,121)
100% 90% 80% 70% 60%
All Others Private Medicare Medicaid Self-Pay (Uninsured)
50% 40% 30% 20% 10% 0%
Hispanic
White
Black
Asian
Other
Unknown
Table 20 below shows health insurance coverage by race/ethnicity for all unique patients seen at ABHEastern Shore, in 2012. As the table shows, most of the patients, about 67 percent overall, were covered by Medicaid. Approximately 64 percent of White patients and 75 percent of Black patients had Medicaid as a primary insurer. ABH-Eastern Shore treats children and adolescents only; therefore, Medicare is not a payer.
Adventist Behavioral Health | 49
TABLE 20. HEALTH INSURANCE COVERAGE BY RACE/ETHNICITY, FOR ALL UNIQUE PATIENTS, ABH-EASTERN SHORE, 2012, (N=287)
Hispanic (%) White (%)
Black (%)
Asian (%)
Other (%)
Medicaid
70.0
64.2
75.0
0
76.9
Private
30.0
35.8
25.0
100
23.1
100%
100%
100%
100%
100%
Total PRIMARY DIAGNOSIS
The Diagnoses tables below show the primary diagnoses of unique patients seen at ABH in 2012. This table shows only the first visit per each unique patient. Therefore, it is possible that different diagnoses were made for patients with multiple visits in 2012. Also, there were often secondary or tertiary diagnoses that are not reflected in the tables below. Table 21 below describes the primary diagnoses for patients treated at ABH-Rockville in 2012. The most common primary diagnosis was ‘episodic mood disorders.’ Mood disorders are characterized by persistent feelings of sadness or fluctuations from extreme happiness to extreme sadness. Mood disorders include bipolar episodes and depressive episodes. Schizophrenic disorders account for approximately 11 percent of the patients seen. For nearly one quarter of patients treated, the medical record does not include any information on the primary diagnosis. TABLE 21. PRIMARY DIAGNOSES OF PATIENTS TREATED AT ABH-ROCKVILLE, 2012 (N=3,121)
Primary Diagnosis
Percent (%)
Schizophrenic Disorders
10.6
Episodic Mood Disorders
52.1
Psychosis (Unspecified)
5.3
Alcohol or drug dependence, or alcohol or drug abuse (non-dependent)
3.1
Depressive Disorder, not elsewhere classified
5.5
Other
0.4
Unknown (No information in medical record)
22.9
Total
99.9 (%)*
*Due to rounding Table 22 shows the primary diagnoses for unique patients treated at ABH-Rockville, stratified by race/ ethnicity. Black patients were most likely to be diagnosed with a schizophrenic disorder (about 18%), compared to 15 percent or less for all other racial/ethnic groups. For all races, episodic mood disorders accounted for the majority of the diagnoses. Asian patients were most likely to be diagnosed with unspecified psychosis, and Hispanic patients were most likely to be diagnosed with depressive disorder (not elsewhere classified). The percentage of patients without a diagnosis recorded in their medical record ranged from about 8 to 10 percent for patients of all races.
50 | Adventist Behavioral Health
TABLE 22.
PRIMARY DIAGNOSES BY PATIENT RACE/ETHNICITY, ABH-ROCKVILLE, 2012 (N=3,121)
Hispanic
White
Black
Asian
Other
Unknown
Schizophrenic Disorders
7.0
11.0
18.2
15.3
11.0
0.0
Episodic Mood Disorders
62.0
66.0
55.7
55.6
66.5
0.2
Psychosis (Unspecified)
5.6
4.2
9.1
12.5
7.2
0.0
Alcohol or drug dependence, or alcohol or drug abuse (nondependent)
3.3
4.2
4.6
2.8
1.5
0.0
Depressive Disorder, not elsewhere classified
12.7
6.2
4.5
4.2
9.2
0.0
Other
1.4
0.4
0.3
0.0
0.5
0.0
Unknown
8.0
8.0
7.6
9.7
4.1
99.8
100%
100%
100%
100%
100%
100%
Total
Table 23 shows the primary diagnoses for all unique patients treated at ABH-Eastern Shore. ABH-Eastern Shore treats children and adolescent patients only. The most common diagnosis among the patients was episodic mood disorders (55%). The second most common diagnosis was attention deficit hyperactivity disorder (12%). For ABH-Eastern Shore patients, the diagnoses that are included in ‘Other’ include the following: unspecified psychosis, anxiety disorder, bulimia, and emotional disturbances. For two patients, there was no diagnosis included in the medical record. TABLE 23. PRIMARY DIAGNOSES OF PATIENTS TREATED AT ABH-EASTERN SHORE, 2012 (N=287)
Primary Diagnosis
Percent (%)
Episodic Mood Disorders
55.1
Adjustment Reactions, including PTSD
9.1
Depressive Disorder, not elsewhere classified
10.1
Disturbance of Conduct, not elsewhere classified
4.9
Attention Deficit Disorder (Child) with Hyperactivity, or Hyperkinetic syndrome
11.8
Other
8.4
Unknown (No information in medical record)
0.7
Total *Due to rounding
100.1%*
Adventist Behavioral Health | 51
Table 24 shows the primary diagnoses for unique patients treated at ABH-Eastern Shore, stratified by patient race/ethnicity. As Table 18 showed above, more than 90 percent of the ABH-Eastern Shore patients were White or Black; therefore, the percentages reported in Table 24 for Hispanic patients (N=10) and Asian patients (N=2) are inflated. For both White and Black patients, episodic mood disorders were the most common diagnoses. Comparatively, White patients were more likely to be diagnosed with depressive disorder, and Black patients were more likely to be diagnosed with disturbance of conduct. TABLE 24. PRIMARY DIAGNOSES BY PATIENT RACE/ETHNICITY, ABH-EASTERN SHORE, 2012 (N=285)
Hispanic
White
Black
Asian
Other
Episodic Mood Disorders
50.0
53.4
56.9
100.0
75.0
Adjustment Reactions, including PTSD
30.0
8.5
9.7
0.0
0.0
Depressive Disorder, not elsewhere classified
20.0
12.2
4.2
0.0
8.3
Disturbance of Conduct, not elsewhere classified
0.0
3.7
9.7
0.0
0.0
ADD (Child) with Hyper-activity, or Hyperkinetic syndrome
0.0
12.7
11.1
0.0
16.7
Other
0.0
9.5
8.3
0.0
0.0
100%
100%
99.9%*
100%
100%
Total *Due to rounding
52 | Adventist Behavioral Health
Selected Quality Measures for Adventist Behavioral Health The Hospital-Based Inpatient Psychiatric Service’s (HBIPS) Core Measure Set consists of seven measures to assess quality of care for patients discharged from free-standing psychiatric hospitals and acute-care hospitals with psychiatric units. The following five measures are reported, by race only, in Table 25. (HBIPS 2 and HBIPS 3, which apply to hours in physical restraint and hours in seclusion, were not included.) \\ HBIPS 1 – Admission screening for violence risk, substance use, psychological trauma history and patient strengths completed \\ HBIPS 4 - Patient discharged on multiple antipsychotic medications \\ HBIPS 5 – Patient discharged on multiple antipsychotic medications with appropriate justification \\ HBIPS 6 – Post discharge continuing care plan created \\ HBIPS 7 – Post discharge continuing care plan transmitted to next level of care provider upon discharge For HBIPS 1, there was nearly 100 percent compliance for all patients. For HBIPS 4 and 5, there was more variation between patients from different racial groups. For example, more than 30 percent of Asian patients were discharged on multiple antipsychotic medications, compared to 15 percent of White patients, and 2 percent of Black patients. However, all patients had higher percentages of being discharged on multiple medications with appropriate justification (HBIPS 5). For White, Black, and Asian patients, a postdischarge continuing care plan was created more than 90 percent of the time (HBIPS 6). However, that plan was not always transmitted to the next level-of-care provider upon the patients’ discharge (HBIPS 7). TABLE 25. HBIPS QUALITY MEASURES BY RACE, ALL PATIENTS, ABH-ROCKVILLE, 2012 (IN PERCENTS)
HBIPS 1
HBIPS 4
HBIPS 5
HBIPS 6
HBIPS 7
White
99.9
14.9
65.0
90.7
86.5
Black
99.6
1.6
77.5
90.8
86.7
Asian
100
31.5
76.5
92.9
89.4
Specialty Care
54 | Specialty Care
Adventist Home Care Services SNAPSHOT OF DIVERSITY Adventist Home Care Services (AHCS), a part of Adventist HealthCare, Inc. (AHC), offers a variety of programs and services to residents in the Washington, DC metropolitan area and suburban Maryland to assist patients while they recuperate from an illness, injury, or surgical procedure. They offer a full range of supportive services to assist with personal care or daily activities. Among the services that they provide are nursing (e.g., cardiac care, wound care, diabetes management, and medication management), rehabilitation (e.g., physical therapy and occupational therapy), and maternal/child services (e.g., lactation support, phototherapy, etc.). The services provided allow patients to receive assistance upon discharge from a hospital or even prevent an initial admission to a hospital. Many avoidable hospital readmissions are related to a lack of support and resources upon discharge from the hospital.53,54 With these and other services, AHCS plays a vital role in filling these gaps and ensuring a continuum of care for patients. With proper discharge planning and access to appropriate medical/clinical support resources, patients are more likely to experience positive outcomes, which may reduce the need for inpatient care. As AHC continues to shift toward a population health approach, home care services will provide critical support to address the health needs of people in the communities we serve. Table 26 below shows the patients who received AHCS services in 2012. More than 5,700 unique patients received services in 2012. These patients accounted for more than 77,035 visits during 2012. Table 25 shows the breakdown of unique AHCS patients, by race/ethnicity. Just more than half of the patients were White (51%) and 35 percent were Black. Hispanic patients and Asian patients accounted for 7 percent and 6 percent of patients, respectively. (Note: See “About the 2013 Health Equity Report” for details on methodology, sources, limitations, inclusions/exclusions, missing data, and other information about the data reported here.) TABLE 26. ALL UNIQUE PATIENTS BY RACE/ETHNICITY, AHCS, 2012 (N=5,736)
Race/Ethnicity
Percent (%)
White
50.8
Black
34.9
Hispanic
7.0
Asian
6.4
Other
0.7
Unknown
0.3
Total
100.1%*
*Due to rounding.
PRIMARY DIAGNOSIS AND HEALTH INSURANCE More than half of AHCS patients were diagnosed as being “not currently sick” or having a “problem that influenced their health status,” which includes being in a post-procedural state, having problems with limbs, having motor or sensory problems, and receiving dialysis (ICD 9 codes V40-V82). Other prevalent diagnoses included diseases of the circulatory system, skin and subcutaneous tissue, and musculoskeletal system.
Specialty Care | 55
Table 27 shows primary health insurance coverage for unique patients who received AHCS services. We are not able to report this information by patient race/ethnicity. However, the data shows that the majority of patients (64%) and visits (75%) were covered by Medicare. Nearly all of the remaining patients were covered by private insurance, including health maintenance organizations (HMOs). Less than 4 percent of all patients and 3 percent of all visits were covered by Medicaid or the patient (uninsured). This data suggests that community members without private insurance who are not Medicare eligible may face significant barriers to accessing the services provided by AHCS. However, it is notable that AHCS had more than 300 charity visits during 2012. TABLE 27. HEALTH INSURANCE COVERAGE FOR ALL UNIQUE PATIENTS, AHCS, 2012 (N=5,736)
Unique Patients (%)
Visits (%) (N=77,035)
Medicare
63.8
74.7
Medicaid
3.2
2.4
Private/HMO
32.7
22.8
Self-Pay (Uninsured)
0.3
0.2
100%
100.1%*
Total *Due to rounding.
Of all the visits that AHCS made in 2012, skilled nursing services and physical therapy accounted for the vast majority of services provided to patients (almost 85%). The third and fourth most common services were home health aide and occupational therapy services. Other services included speech/language and medical social work. INTERPRETER SERVICES Figure 22 shows the languages requested most frequently for interpretation by phone at AHCS. AHCS placed more than 280 calls, exceeding 3,300 minutes. As seen in Figure 22, the vast majority of calls placed were for Spanish; the second and third most requested languages were Mandarin and Korean. In addition to the languages highlighted below, calls were placed for seven additional languages, including Amharic and Russian (All Others, 3.2%). FIGURE 22. OVER-THE-PHONE INTERPRETER USE BY NUMBER OF CALLS, AHCS, 2012
Spanish 92.9%
Other 7.1%
All Others 3.2% Korean 1.8%
Mandarin 2.1%
56 | Specialty Care
Adventist Rehabilitation Hospital of Maryland SNAPSHOT OF DIVERSITY Adventist Rehabilitation Hospital of Maryland (ARHM), is the first and only acute rehabilitation hospital in Montgomery County offering specialized inpatient and outpatient treatment for persons with functional limitations. ARHM primarily serves adults 18 years or older, who largely reside in Montgomery County (78%) or Prince George’s County (18%). ARHM has two hospital locations: a free-standing 55-bed hospital adjacent to SGAH in Rockville, and a 32-bed hospital located in WAH in Takoma Park. Outpatient services are provided at both the Rockville location and a community-based center in Silver Spring, Maryland. ARHM offers comprehensive rehabilitation programs for traumatic brain injuries, spinal cord injuries, strokes, amputations, orthopedic injuries and surgeries, sports related injuries, work-related injuries, cardiopulmonary conditions and neurological disorders. Currently, ARHM is the only acute rehab facility within a five-state region with a Commission on Accreditation Facilities (CARF) accreditation for all four of its specialty programs: stroke, brain injury, spinal cord injury and amputee. It was one of the first acute rehabilitation facilities in the nation to earn specialty accreditation for its amputee program. Further, ARHM was recognized in 2013 by the Maryland Patient Safety Center (MPSC) for its innovative patient safety program to reduce acute-care readmissions and increase patient safety. Like AHC’s other specialty entities, the specialized services provided by ARHM illustrate the organization’s commitment to population-based care and dedication to improve the overall health and well-being of the communities we serve. Approximately 1,500 unique inpatients were treated at ARHM in 2012. The stratification of these patients by race/ethnicity is illustrated in Table 28 below. Data on outpatients are not presented here. The majority of inpatients treated at ARHM (about 58%) were White. The percentage of White patients is nearly double the percentage of Black patients, who account for about 30 percent of the patient population. Hispanic patients and Asian patients account for nearly 6 and 7 percent of the remaining patients, respectively. (Note: See “About the 2013 Health Equity Report” for details on methodology, sources, limitations, inclusions/ exclusions, missing data, and other information about the data reported here.) TABLE 28. ALL UNIQUE PATIENTS BY RACE/ETHNICITY, ARHM, 2012 (N=1,571)
Race/Ethnicity
Percent (%)
White
57.5
Black
30.0
Hispanic
5.7
Asian
6.6
Other/Unknown
0.2
Total
100%
Specialty Care | 57
HEALTH INSURANCE Table 29 below shows health insurance coverage for inpatients seen at ARHM for 2012. Sixty-two (62%) percent of inpatients were covered by Medicare, while 30 percent had private or commercial insurance. Less than 10 percent of inpatients were covered by Medicaid or were uninsured. TABLE 29. HEALTH INSURANCE COVERAGE FOR ALL UNIQUE PATIENTS, ARHM, 2012 (N=1,571)
Percent (%) Private Insurance
29.1
Medicare
61.9
Medicaid
7.0
All Others
1.6
Self-Pay (Uninsured)
0.4
Total
100%
INTERPRETER SERVICES Figure 23 shows the languages most frequently requested for phone interpretation at ARHM. ARHM placed more than 870 calls in 2012, exceeding 14,300 minutes. Spanish was the most frequently requested language, at about 53 percent. Mandarin was the second most requested language, at almost 25 percent. Russian and Farsi were the third and fourth most requested languages, respectively. In addition to the languages included in Figure 23, calls were placed for an additional 14 languages, including Tagalog and Gujarati (All Others, 3.8%). FIGURE 23. OVER-THE-PHONE INTERPRETER USE BY NUMBER OF CALLS, ARHM, 2012
Mandarin 24.8%
Spanish 52.9%
Russian 4.9%
Other 17.4%
Vietnamese 2.4% Korean 2.3% Cantonese All Others 2.6% 3.8% Haitian Creole Farsi 2.9% 3.4%
Affordable Care Act Implementation in the State of Maryland Maryland Governor Martin O’Malley signed into law the Maryland Health Improvement and Disparities Reduction Act of 2012 to expand access to care, reduce chronic illness, and promote equity particularly in underserved areas known as Health Enterprise Zones (HEZs). The HEZ initiative was created to reduce racial and ethnic health disparities, improve health care access and outcomes in underserved populations, and reduce hospital readmissions. Five locations in Maryland designated as health enterprise zones in 2013 will receive a range of incentives, benefits, and grant funding to address disparities: MedStar St. Mary’s Hospital, Greater Lexington Park (St. Mary’s County); Prince George’s County Health Department, Capital Heights; Dorchester County Health Department, Dorchester and Caroline counties; Bon Secours Baltimore Health System, West Baltimore; and Anne Arundel Health System, Annapolis. For additional information about the HEZ initiative and specific proposals, visit http://dhmh.maryland.gov/healthenterprisezones/ SitePages/Updates.aspx. Maryland’s law to reduce health disparities includes requirements for health care organizations to collect standard categories of race and ethnicity and report efforts to track and reduce disparities. In 2013, the Health Services Cost Review Commission of the Maryland Department of Health and Mental Hygiene (HSCRC) provided funding to the Center on Health Disparities at Adventist HealthCare to provide race, ethnicity, and language data collection training to Maryland hospital staff including patient registrars, quality coordinators, admission directors, and leadership. The Center and the Institute for Patient- and FamilyCentered Care (IPFCC), in partnership with HSCRC and the Maryland Hospital Association (MHA), held three Train-the-Trainer sessions on how to collect and use patient data and address patients’ concerns at MHA in Elkridge (Central Maryland), Shore Health System, The Memorial Hospital at Easton (Eastern Maryland); and Frederick Memorial Hospital in Frederick (Western Maryland). Training sessions such as these serve as a valuable resource to hospital leadership and staff as they strive to be in compliance with data reporting requirements outlined by HSCRC. Standardized collection of patient demographic data is important to inform quality improvement efforts, address needs of vulnerable populations, and ultimately reduce disparities. Through the collaborative work of all the partners on this project, hospitals across the state are now well-equipped to collect accurate data and provide the highest quality care to all residents of the state of Maryland.
Efforts to Reduce Readmissions
60 | Efforts to Reduce Readmissions
BACKGROUND As a part of its strategic plan for 2010–2014, Adventist HealthCare (AHC) has employed a strategy of providing population-based care to the communities it serves. Through the use of innovative and patientcentered discharge processes and the cultivation of community partnerships, AHC has become a leader in its efforts to ensure patient wellness after discharge from its hospitals. “Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year.”55 While not all readmissions can be predicted or prevented, it is estimated that more than $17 billion each year pays for readmissions that are in fact preventable.56 Adventist Rehabilitation Hospital of Maryland (ARHM) and AHC’s acute-care hospitals—Shady Grove Adventist Hospital (SGAH) and Washington Adventist Hospital (WAH)—participate in the Partnership for Patients, a CMS program with goals to improve patient safety and support effective transitions from hospitals to other settings.57 Our hospitals are part of Premier’s Hospital Engagement Network (HEN), a collaborative of 450 hospitals and the largest CMS-approved HEN in the nation. The HEN focuses on multiple areas that affect patient safety including preventable hospital readmissions. HEN rates are calculated using the Admission-Readmission Revenue (ARR) method, giving credence to Maryland’s modernized all-payer rate-setting system for hospital services, an unprecedented effort to enhance care for patients, improve health care outcomes, and control costs across the state.58 Participation in the HEN provides significant opportunities to exchange best practices among hospitals across the country to address care and safety for Medicare program participants. Because of AHC’s commitment to quality and safety and its partnership with Walgreens, Premier invited WAH to present their efforts at their annual Breakthroughs Conference in November 2013. A CALL TO ACTION The need for action around reducing preventable readmissions has recently been reinvigorated with a sense of urgency due to new provisions in the Patient Protection and Affordable Care Act (ACA). The Medicare Readmission Reduction program, which went into effect October of 2012, reduced payments up to one percent for hospitals with excess preventable readmission rates related to heart failure, acute myocardial infarction, and pneumonia.59 This deduction will increase to two percent in 2014 and peak at three percent in 2015, while also expanding to conditions including chronic obstructive pulmonary disease and coronary bypass grafting. In addition to financial penalties for doing poorly, new Medicare policies have been instituted to provide financial rewards to those hospitals that are meeting or exceeding certain quality measures. Several of these quality measures focus on discharge practices such as informing patients of symptoms to look out for post-discharge and inquiring if they will have the necessary help and support once they return home.60 A high rate of preventable readmissions is often a complex problem stemming from multiple causes, and therefore requires a multifaceted approach to remedy. Over the past two years, WAH has successfully implemented programs to enhance the discharge process for all patients, adopted an added focus on high-risk patients and cultivated community partnerships to improve the continuum of care post-discharge. Through its efforts, WAH has seen a 4.5 percent reduction in readmissions, decreasing from 11 percent in December of 2011 to 6.5 percent in September of 2013. At the same time, SGAH has implemented programs to assist in the post-discharge care of high-risk patients, partnering with post-acute care providers and using a disease-specific model to address the most vulnerable patients. SGAH has seen a 1.07 percent reduction in readmissions, decreasing from 6.83 percent in December of 2011 to 5.76 percent in August of 2013. The hospital continues to work on other disease specific initiatives to reduce readmissions.
Efforts to Reduce Readmissions | 61
ARHM was recognized in 2013 by the Maryland Patient Safety Center (MPSC) for its innovative patient safety program to reduce acute-care readmissions and increase patient safety. ARHM instituted new processes in the fall of 2010 to decrease the number of patients readmitted to acute-care hospitals by implementing a collaborative clinical review of each patient throughout the transfer process. According to the hospital’s medical director, the program has resulted in fewer patients returning to acute-care hospitals and more patients being discharged home. Nationally, their “discharge to home” rates are in the 80th percentile (i.e., better than 80%) of all hospitals in the country. In collaboration with partners Carelink, Community Clinic Inc., Family Services, Inc., and WAH, Adventist Behavioral Health (ABH) is working to better serve the chronically mentally ill by providing necessary support in the community and expanding outpatient services. ABH has increased its outreach to the community using multiple approaches to engage families in the treatment process. From family days to providing transportation to treatment centers, and using videoconferencing technologies, these efforts have increased families’ access to patients, contributed to positive treatment outcomes, and reduced the incidence of readmission. OVERVIEW OF PROGRAMS Enhancing the Discharge Process Following discharge, patients often return home feeling overwhelmed and unsure of next steps. In order to simplify the transition, AHC has been working to ensure that all discharged hospital patients who need support with follow-up care receive assistance with finding a physician and scheduling a primary care appointment before they leave the hospital. For instance, ABH is working with payers to establish what are known as “bridge” services for individuals who have difficulty scheduling follow-up outpatient care within seven days. Through a partnership with Walgreens, both WAH and SGAH have been able to ensure that patients can easily fill prescriptions and speak to a pharmacist prior to discharge. The Walgreens Bedside Prescription Delivery Service, initiated in June of 2011, is available to all inpatients and includes a follow-up call from the pharmacist within 48–72 hours of discharge. During the follow-up call, the pharmacist is able to answer questions about medications and provide additional patient education. Among those patients taking part in this program, there has been an increase in medication compliance and as a result, improved health status and fewer emergent needs. This patient resource has also contributed to reducing readmissions, thus helping individuals stay well and complete a prescribed medication course. Additional resources for patients are available as needed to assess and support patients’ discharge needs (e.g., resources to address behavioral health needs, outpatient case management, and help with transition to adult day care). Also, both WAH and SGAH are enrolled as 340B outpatient pharmacy programs with Walgreens. Through this federal program, which provides reduced pricing for most drugs, money is returning to the hospitals to be applied toward the cost of medication for underserved patients. Adopting an Added Focus on High-Risk Patients Each patient receiving care at AHC hospitals varies both in their condition and in the resources and support to which they have access. In order to ensure that those with more complex conditions and circumstances have the added support they need when they leave the hospital, hospital staff (including nurse managers, case managers, and transition care team members) identify patients at high-risk for readmission and then provide appropriate follow-up care.
62 | Efforts to Reduce Readmissions
Patients identified as high-risk (e.g., non-adherent to recommendations, having multiple co-morbidities, diagnosed with congestive heart failure, or lacking a support system or resources) are able to benefit from multiple programs designed to help navigate the road to recovery. SGAH and WAH participate in the WellTransitions Program (in partnership with Walgreens), which provides high-risk patients with three follow-up calls from a pharmacist within 30 days of leaving the hospital. During these follow-up calls, pharmacists are able to address questions around prescribed hospital medications, home medications, side effects, dosage and any additional health issues the patient may have. In addition, both hospitals— together with Adventist Home Care Services (AHCS)—have developed the Healthy Heart at Home program that focuses on patients with congestive heart failure. Pill boxes and scales are provided to patients to help them better manage their disease. A cardiac nurse assists patients with education, family support, nutrition, and medication management as well. In 2013, WAH and partner Conifer Health Solutions launched the My Health Place® program, which utilizes the model of a personal healthcare nurse. Through this program, the transitional care team ensures that all discharged high-risk patients have a scheduled follow-up appointment before leaving the hospital. Each of these patients receives a My Health Place® Passport booklet which includes the name and number of their doctor as well as the date, time and location of their follow-up appointment. Additional helpful information such as a phone number to call with questions, reminders of what to bring to the follow-up appointment, the duration of the hospital stay and the procedures that were performed, is also included. The Passport is available in English, Spanish, French, and Amharic. In addition to providing patients with a Passport, a member of the care team meets with each patient prior to discharge and conducts three follow-up calls within 30 days of leaving the hospital. The care team implements individualized interventions often meeting the needs of patients within one week of discharge. Interventions may include support for a spouse or loved one, assistance with sub-acute placement, referrals to wound care to avoid unnecessary readmission, home health services, transition to a nursing home or hospice care, and arranging transportation. Developing Community Partnerships AHC fosters partnerships with community members and organizations to improve care transitions for discharged patients. A Community Coalition to Improve Care Transitions was initially established as a method for each hospital to begin thinking outside the box to develop care coordination solutions for patients and reduce readmissions. The coalition at WAH, launched in March of 2013, has since grown into a partnership between 35 different health services throughout the community with a mission to improve the transition of care from hospital to community for residents of the region. The partners meet monthly to collaboratively and creatively solve patient challenges with an aim to reduce preventable readmissions at acute-care hospitals by 20 percent over a three year period. At SGAH, the coalition to develop and strengthen partnerships among providers serves patients throughout the greater community. In May of 2013, the coalition began meeting quarterly with an aim to reduce readmissions by 10 percent over the following 12 months. SGAH has several other successful partnerships in place through which they are able to offer patients invaluable resources (e.g., ranging from transportation to outpatient case management) to improve their health and primary care following discharge. In order to reach those in need of health care before they even come to the emergency department, AHC has developed direct partnerships with three local housing facilities—and a fourth in progress—to provide accessible primary care. Through these partnerships, AHC has increased access to primary care services for elderly and underserved populations who otherwise may have gone without care.
Efforts to Reduce Readmissions | 63
FUTURE DIRECTIONS While it is difficult to determine the impact of programs to reduce readmissions, both WAH and SGAH have been successful in achieving an overall reduction in readmission rates over the course of one and a half years. Going forward, AHC will continue to grow its readmission reduction initiatives and community partnerships while also expanding its focus to outpatient care. Beginning in 2014, efforts will be put in place at WAH to address the needs of individuals who pay frequent visits to the emergency department. One such program will assist patients with becoming better advocates for their own health. Individuals at high risk for emergency department visits or for not following through with doctor appointments will be matched with volunteer health coaches. These coaches will be available to accompany patients to their doctor appointments. Looking forward for SGAH, greater emphasis will be put on addressing needs of uninsured and homeless patients. Potential efforts include a partnership with the Montgomery County Agency on Aging to increase medical beds and funding for uninsured and homeless patients needed for short-term rehabilitation or continued treatment. Additionally, Shady Grove would like to obtain funding for increased community case management to assist with medication refills, physician follow-up and compliance with treatments for homeless county residents.
Conclusion and Next Steps
Conclusion and Next Steps | 65
Conclusion and Next Steps The Institute for Healthcare Improvement’s Triple Aim for improving the U.S. healthcare system focuses on improving patient experience, reducing costs for the population, and improving the health of the community.61 Meeting these strategic aims to achieve health equity requires targeted efforts that “eliminate potentially avoidable differences or disparities in health between socially advantaged and disadvantaged groups”.62 The 2013 Adventist HealthCare Health Equity Report presents a comprehensive snapshot of the patient populations—stratified by race, ethnicity, and preferred language—that received care at Washington Adventist Hospital (WAH) and Shady Grove Adventist Hospital (SGAH) in 2012. In addition, we include data from specialty care entities Adventist Behavioral Health, Adventist Rehabilitation Hospital of Maryland, and Adventist Home Care Services. The report presents patient demographics and information about hospital readmissions, quality measures, primary diagnoses, patient experiences with care, and use of interpreter services for different populations receiving care at Adventist HealthCare hospitals and other entities. At the end of last year’s Health Equity Report, we offered a set of recommendations for hospitals and healthcare systems to improve quality of care and outcomes. 1. Improve patient demographic data collection and increase transparency by reporting hospital performance data by race, ethnicity, and language preference data. 2. Monitor differences in quality of care and healthcare outcomes to inform hospitals’ strategic goals, develop community outreach programs, and target quality improvement efforts. 3. Implement data-driven interventions to improve healthcare quality and outcomes. 4. Promote the provision of culturally competent, patient-centered care. This year’s report highlights specific initiatives at Adventist HealthCare (AHC) to connect mission-driven strategies with quality and patient experience, transitions in care, and partnerships to improve outcomes for people and communities. AHC has implemented various strategies to identify and monitor differences in health status that lead to inequalities in care among minority populations (Recommendations 2-3). In the summer of 2013, the Center on Health Disparities partnered with the Institute for Patient- and Family-Centered Care, Maryland Hospital Association, and the Health Services Cost Review Commission (HSCRC) to provide race/ethnicity and language data collection training to Maryland hospitals in order to ensure accurate data collection and compliance with state data reporting requirements (Recommendations 1, 4). Hospitals equipped with the knowledge and resources to collect, use, and monitor standardized patient demographic data are able to implement data-driven interventions that align with identified community health needs and enhance community benefit reporting. Along with information from this report and findings from needs assessments, AHC will be able to assess its progress at addressing disparities and community health needs and promoting culturally competent care (Recommendations 2, 4). AHC’s community health needs assessment reports and implementation plans for its hospitals and other entities will be publicly available by the end of this year and early next year. Next steps will include rolling out initiatives to address the needs and concerns of individuals and populations in the healthcare system’s service areas (Recommendation 3). Hospitals are embracing the idea of better managing “transitions of care” and ensuring that patients experience a smooth transition from inpatient to outpatient care. Population-based care and access to care are important strategic goals for Adventist HealthCare’s hospitals; these goals are informed by community input and quality improvement efforts focused on improving the health of people in our communities (Recommendation 2). Specifically, collaborative population-based initiatives such as the Community Coalitions to Improve Care Transitions, patient and family engagement, and patient safety programs have been effective at improving outcomes and reducing preventable hospital readmissions (Recommendation 4).
66 | Conclusion and Next Steps
In our last report, we stated that effective patient-provider communication is essential to providing highquality, patient-centered care, and is necessary for patient safety. Patient experience data collected from patients who speak a language other than English is an important part of providing population-based care and demonstrates compliance with national standards for effective communication in health care. In the third quarter of 2013, WAH began conducting patient experience surveys with limited English-proficient patients in response to the growing proportion of Hispanic patients being served there. Patient-provider communication is a key factor in perceived experience of care. Also, patient-centered, culturally appropriate discharge instructions are critical tools that help patients understand next steps for follow-up care upon leaving the hospital, which factors into our ability to provide the best care possible (Recommendation 4). Next steps might include analysis of patient experience data in specific departments implementing culturally competent, population-based initiatives. Information beyond race and ethnicity are important indicators to measure to ensure that patients’ needs are met (Recommendations 1–3). Key indicators of interest might include age, gender, sexual orientation, income, education, insurance status, religion, health status, and disability status. In some cases, it may be necessary to survey specific samples of people from different populations using various methods (i.e., using online surveys vs. paper or phone surveys) to assess perceptions of organizational cultural competence or the effectiveness of programs and initiatives (e.g., interpreter services). In conclusion, achieving health equity will require shifting the focus beyond access and health care delivery to quality and appropriateness of care as well as addressing disparities and numerous factors that play a role in shaping population health outcomes. We encourage leadership in our hospitals and other healthcare organizations to use valuable hospital data and information about community needs to shift their focus to population health, health equity, and healthcare quality improvement.
References
68 | References
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
13. 12.
14.
Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27(1), 167– 194. Kindig, D. (2007). Understanding Population Health. Madison: Blackwell Publishing. Kindig, D. & Stoddart, G. (2003). What is population health? American Journal of Public Health, 380–383. Center on Health Disparities 2010 Progress Report. Partnering Toward a Healthier Future: Social Determinants of Health. Adventist HealthCare, Inc. Rockville, MD. Office of Minority Health and Health Disparities (2012). Maryland Chartbook of Minority Health and Health Disparities Data 2012. Third edition. Maryland Department of Health and Mental Hygiene. Retrieved from http://dhmh.maryland.gov/mhhd/SitePages/ Health%20Equity%20Data.aspx Whitehead, M. (1992). The concepts and principles of equity in health. International Journal of Health Services, 22(3), 429–445. Institute of Medicine (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press. Agency for Healthcare Research and Quality (2012). National Healthcare Disparities Report (13-0003). U.S. Department of Health & Human Services. Retrieved from www. ahrq.gov/research/findings/nhqrdr/index.html May, E. L. (2013). Population health management: Defining the provider’s role. Healthcare Executive, 20–29. Stoto, M. A. (2013). Population health in the Affordable Care Act era. Academy Health, 1–6. Center on Health Disparities 2011 Progress Report. Partnering toward a healthier future: Health disparities in the era of reform implementation. Adventist HealthCare, Inc. Rockville, MD. Ibid. 1 U.S. Department of Health and Human Services (2011). Health equity & disparities. National Partnership for Action to End Health Disparities. Retrieved from http:// minorityhealth.hhs.gov/npa/templates/ browse.aspx?lvl=1&lvlid=34 Ibid. 6
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Morrissey, J. (2012). 10 facts about population health. Trustee, 10–14. Managing population health: The role of the hospital. Health Research & Educational Trust, Chicago: April 2012. Retrieved from www.hpoe.org Ibid. 16 Centers for Disease Control and Prevention. Chronic diseases: The power to prevent, the call to control: At a glance 2009. U.S. Department of Health & Human Services. Retrieved from http://www.cdc.gov/ chronicdisease/resources/publications/aag/ chronic.htm Institute of Medicine (2013). Population health implications of the Affordable Care Act: Workshop summary. Washington, DC: The National Academies Press. Goldberg, A. (2013). It matters how we define health care equity. Commentary, Institute of Medicine: Washington, DC. Retrieved from http://www.iom.edu/Home/Global/ Perspectives/2013/DefineHealthCareEquity. aspx. Center on Health Disparities 2012 Progress Report. Partnering toward a healthier future. Adventist HealthCare Health Equity Report. Adventist HealthCare, Inc. Rockville, MD. Hasnain-Wynia, R., Kang, R., Landrum, M. B., Vogeli, C., Baker, D. & Weissman, J. (2010). Racial and ethnic disparities within and between hospitals for inpatient quality of care: An examination of patient-level Hospital Quality Alliance measures. Journal of Health Care for the Poor and Underserved, 21(2), 629–648. Centers for Medicare & Medicaid Services (2013). Readmissions Reduction Program. Retrieved from http://www.cms.gov/ Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/ReadmissionsReduction-Program.html Health Services Cost Review Commission. Post-meeting Documents from the 497th Meeting of the Health Services Cost Review Commission. May 1, 2013. Maryland Department of Health and Mental Hygiene. Retrieved from http://www.hscrc.state.md.us/ documents/CommissionMeeting/2013/05-01/ hscrc-post-comm-meet-docs2013-05-01.pdf.
References | 69
25.
26.
27.
28.
29.
30.
31.
34. 32. 33.
35.
36.
37.
Young, G.J., Meterko, M., & Desai, K.R. (2000). Patient satisfaction with hospital care: Effects of demographic and institutional characteristics. Medical Care, 38(3), 325– 334. Murray-García, J., Selby, J., Schmittdiel, J., Grumbach, K. & Quesenberry, C. (2000). Racial and ethnic differences in a patient survey: Patients’ values, ratings, and reports regarding physician primary care performance in a large health maintenance organization. Medical Care, 38(3), 300–310. Elliott, M., Lehrman W., Goldstein, E., Hambarsoomian, K., Beckett, M., Giordano, L. (2010). Do hospitals rank differently on HCAHPS for different patient subgroups? Medical Care Research and Review, 67(1), 56–73. Retrieved from http://mcr.sagepub. com/content/67/1/56 Sauter, M., Hess, A. (2012). America’s best (and worst) educated states. Fox Report. Retrieved from http://www.foxbusiness.com/ personal-finance/2012/10/15/americas-bestand-worst-educated-states/ Kurtzleben, D. (2013). The 10 most educated U.S. cities. U.S. News. Retrieved from http://www.usnews.com/news/best-cities/ slideshows/the-10-most-educated-us-cities/9 Ibid. 27 Goldstein, E., Elliott, M.N., Lehrman, W.G., Hambarsoomian, K., Giordano, L.A. (2010). Racial/ethnic differences in patients’ perceptions of inpatient care using the HCAHPS survey. Medical Care Research and Review, 67(1), 74–92. Ibid. 28 Ibid. 29 U.S. Department of Health & Human Services. What is mental health? Retrieved from MentalHealth.gov website: http://www. mentalhealth.gov/basics/what-is-mentalhealth/index.html The National Alliance on Mental Illness (2013, March). Mental illness facts and numbers. Retrieved from http://www.nami. org/factsheets/mentalillness_factsheet.pdf National Institute of Mental Health (2006). Mental healthcare cost data for all Americans. Retrieved from http://www.nimh.nih.gov/ statistics/4COST_AM2006.shtml Ibid. 35
38.
39.
40.
41.
42.
43.
44.
45.
46.
National Alliance on Mental Illness, State Advocacy 2010. State statistics: Maryland. Retrieved from http://www.nami.org/ C o n t e n t M a n a g e m e n t / C o n t e n t D i s p l a y. cfm?ContentFileID=93498 Anxiety & Stress Center, P.C. Generalized anxiety disorder (GAD). Retrieved from http://anxiety-stresscenter.com/anxiety/ generalized-anxiety-disorder Maryland Behavioral Risk Factor Surveillance System, 2009. Montgomery County Behavioral Health Profile. http://www. marylandbrfss.org/cgi-bin/broker.exe Peninsula Regional Medical Center (2011). Creating healthy communities. Community Dashboard. Indicators for Wicomico County. Retrieved from http://www.peninsula.org/ body.cfm?id=627&oTopId=627 National Institute on Minority Health and Health Disparities. Health disparities – mental health. National Institutes of Health. Retrieved from http://www.nimhd.nih.gov/ hdFactSheet.asp Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). National Alliance on Mental Illness (2005). Eliminating disparities in mental health: An overview. Arlington, VA. Retrieved from http:// www.nami.org/Content/NavigationMenu/ Find_Support/Multicultural_Support/ Sharing_Hope1/DisparitiesOverview.pdf Substance Abuse and Mental Health Services Administration (2012). Mental health, United States, 2010. HHS Publication No. (SMA) 124681. Rockville, MD. Retrieved from http:// www.samhsa.gov/data/2k12/MHUS2010/ MHUS-2010.pdf Office of Minority Health (2013). Mental health data/statistics. U.S. Department of Health & Human Services. Retrieved from http://www.minorityhealth.hhs.gov/templates/ browse.aspx?lvl=3&lvlid=539
70 | References
47.
50. 48. 49.
53. 51. 52.
54.
55.
56.
57.
58.
59.
60.
Williams, D. R., Jackson, J., González, H. M., Neighbors, H., Nesse, R., Abelson, J. M., & Sweetman, J. (2007). Prevalence and distribution of major depressive disorder in African Americans, Caribbean Blacks, and Non-Hispanic Whites. Archives of General Psychiatry, 64(3), 305–315. Ibid. 44 Ibid. 45 Maryland Department of Health and Mental Hygiene, Vital Statistics Administration (2011). Maryland vital statistics annual report 2011. Retrieved from http://dhmh.maryland. gov/vsa/Documents/11annual.pdf Ibid. 43 Ibid. 44 Van Walraven, C., Seth, R., Austin, P. & Laupacis, A. (2002). Effect of discharge summary availability during post-discharge visits on hospital readmission. Journal of General Internal Medicine, 17(3), 186–192. Nelson, E., Maruish, M. & Axler, J. (2000). Effects of discharge planning and compliance with outpatient appointments on readmission rates. Psychiatric Services, 51(7), 885–889. Centers for Medicare & Medicaid Services. Community-based care transitions program. Retrieved from http://innovation.cms.gov/ initiatives/CCTP/index.html Lavizzo-Mourey, R. (2013). In the revolving door: A report on U.S. hospital readmissions. Retrieved from http://www.rwjf.org/content/ dam/farm/reports/reports/2013/rwjf404178 Premier, Inc. (2013). Partnership for Patients. Retrieved from https://www.premierinc. com/safety/topics/HAI/HAI-Partnership-forpatients.jsp Maryland Department of Health and Mental Hygiene (2013). DHMH posts revised proposal for modernization of MD’s all-payer hospital system for comment. Retrieved from http://dhmh.maryland.gov/newsroom1/ Pages/DHMH-Posts-Revised-Proposal-forModernization-of-MD’s-All-Payer-HospitalSystem-for-Comment.aspx Ibid. 23 Burton, R. (2012). Improving care transitions (Policy Brief 9-13). Retrieved from http:// www.healthaffairs.org/healthpolicybriefs/ brief.php?brief_id=76
61.
62.
Institute for Healthcare Improvement (2013). The IHI triple aim. Retrieved from http://www. ihi.org/offerings/Initiatives/TripleAim/Pages/ default.aspx Ibid. 1
References | 71
Acknowledgments This report is the result of collaborative efforts among Adventist HealthCare staff and interns across the health system. A great deal of gratitude is given to the members of the report planning committee for their valuable contributions to the report: Joy Gill, Robert Wells, Peter Mbugua, Arumani Manisundaram, Marcos Pesquera, Deidre Washington, and Marilyn Lynk. Debra Illig, Joy Gill, and Khyati Mehta helped with interpreting quality performance data and shared information on system-wide efforts to improve patient quality and safety. Robert Wells and Daymara Hernandez provided detailed hospital performance data as well as data on readmissions. Peter Mbugua helped with gaining access to and conducting analysis of patience experience data and described ongoing hospital initiatives to improve patient experience of care. Mairene Win, Pam Woynicz, Caterina Pangilinan, Dawn Chriss, Lynette Godhard, Barbara Toops, and Clarencia Stephen provided assistance with gathering entity specific data, information on patient demographics, various process and outcome metrics, and best practices to improve health care outcomes. Judith Kurtis and Jo Cimino provided detailed information about efforts to reduce readmission rates through community-based initiatives and partnerships to improve care transitions. Cindy Glass and Danielle Lewald assisted with editing and facilitated efforts to format and print the report for publication and dissemination. Special thanks goes to the Center for Health Equity and Wellness staff, who have worked tirelessly to improve the way data are collected, monitored, stored, retrieved and reported throughout the Adventist HealthCare system. Our gratitude goes to Dr. Deidre Washington for her tremendous efforts at data gathering, analysis, interpretation, and writing, and for managing contributions to the report. Tiffany Capeles provided creative leadership and perseverance in the design and production of the report. Talya Frelick and Eme Martin shared valuable information, especially on language services and needs assessment findings, and provided unending support in the development of the report. Graduate interns Christopher Smith and Gina Maxham worked diligently and independently to prepare sections on patient experience, quality performance, and readmission reduction efforts. Research Assistant, Nadine Monforte, along with undergraduate interns Michele Troutman, Akash Syngal, and Guofan Li, provided assistance with background information, references, and data analysis. Last, but not least, Marcos Pesquera and Dr. Marilyn Lynk provided continuous leadership and encouragement in the development of this informative report, leveraging stakeholders at AHC, reviewing drafts, and managing planning and production through the year.
Adventist HealthCare Center for Health Equity and Wellness 820 West Diamond Avenue • Suite 400 • Gaithersburg, MD 20878 • 301-315-3677 http://www.adventisthealthcare.com/disparities