A note from Catholic Health’s President & Chief Executive Officer
We’re all part of the solution.
Dear Colleagues,
Catholic Health has a comprehensive plan for enhancing Health Equity across our service area. The pages you’re about to read through will show you just how—and where you play an indispensable role.
The sad truth is that many people—both nationally and regionally—suffer a vastly disproportionate amount of preventable disease. These are largely driven by the social determinants of health (SDOH): dietary habits, neglect and lack of access to quality health care.
We can do something about this, and Catholic Health is committed to doing so. Under the leadership of Dr. Lawrence Eisenstein, we have a comprehensive program to address the economic and social obstacles to good health.
Rooted in mission, Catholic Health believes health care is a right, not a privilege. That’s why we treat all patients in need of our services, regardless of their ability to pay. It’s also why we have proactive programs designed to bring exceptional health care to our underserved communities.
By working together, we can bend the disease curve. As you ramp up access to quality care, you address those SDOH. As you screen for and detect disease at its earliest stages, you make it possible to preempt serious, long-term debilitating diseases.
And that computes to longer, healthier lives as well as sharp reductions in health care costs.
I thank you for being part of this all-important effort.
Patrick O’Shaughnessy, DO, MBA President & CEO
Introduction
Catholic Health is a faith-based health care delivery organization, predominantly serving the residents of Nassau and Suffolk counties on Long Island. Comprised of 6 hospitals, 3 skilled nursing facilities, vibrant home care service delivery, home hospice, and thousands of providers across Long Island, Catholic Health is proud of our mission of mercy, and considers mission and health equity as part of everything that is done at Catholic Health facilities and by its providers.
Executive Summary
In 2022, Catholic Health set out to establish and incorporate a strategy and path forward for a newly formed Community and Public Health Program, of which health equity would be at the core. The inaugural Health Equity Written Strategic Plan 2023 – 2024 was released in the fall of 2023. Now we present the 2024 – 2025 Health Equity Written Strategic Plan! This year’s plan looks back on the first full year of efforts prescribed by the Health Equity Strategic Plan and provides an update on objectives and direction. Further, this plan adds new objectives based on the incredible growth of Catholic Health’s equity initiative.
In line with regulatory requirements, Catholic Health has advanced its work towards health equity. In this report, updated data evaluation is presented including social vulnerability and REaL data (Race, Ethnicity, and language). Led by our new Director of Epidemiology and Public Health Analytics, the data is stratified and analyzed. Measures have been evaluated to assess the specific needs of the communities we serve, and to guide strategic operations going forward, with the goal of achieving health equitable outcomes, and improving the health of our patients.
The pillars of the Community Health Roadmap (see figure 1.0) have not changed. Catholic Health has committed to improving the
health of the people within the communities we serve. This Health Equity Strategic Plan evaluates opportunities for improvement, and identifies deliverables, objectives and associated time frames. In last year’s version, one of the Community Health Roadmap deliverables included the creation of a Health Equity taskforce at Catholic Health. The taskforce, referred to as the Health Equity Leadership Council (HELC) recently celebrated its first anniversary! With representation from all campuses and major departments, the HELC and its four subcommittees made great strides during the first year! These efforts are summarized in the Plan, and the HELC is a vital source of objectives moving forward. Much has changed over the course of a year as it relates to health equity.
The New York State 1115 Medicaid Waiver was enacted, new equity-related requirements from the Centers for Medicare and Medicaid (CMS) have changed the way our practices screen for Social Determinants of Health (SDOH), and the overall awareness of the need for Catholic Health to incorporate equity-specific actions has heightened. This report summarizes the health equity efforts undertaken by Catholic Health, and provides a strategic plan going forward.
New this year
Following last year’s inaugural edition, this year’s edition of the written Health Equity Strategic Plan adds a few new features and sections. Data collection was redesigned by our newly hired Director of Epidemiology and Public Health Analytics with a focus on establishing baselines which can be measured in an ongoing fashion. Data dashboards are in production. Future strategic planning will be based on statistical analysis and program evaluation.
This year’s edition also describes the efforts of the Health Equity Leadership Council, which completed its first year in Spring of 2024. The efforts of each subcommittee are described with a summary of the assigned goals and objectives, and the results. There is also a list of new objectives and future initiatives by subcommittee. In the previous edition of this publication, objectives were listed by pillar of the Community Health Roadmap. For continuity we kept those, and identified completion, progress, or lack thereof next to each objective.
Major projects completed this year include a comprehensive set of listening sessions with community partners, and the resulting findings are enclosed. Also we present the impressive results of the formal expansion and process of having a Catholic Health Speakers Bureau, which now represents speakers capable of presenting in 26 languages!
Lastly, for the campus-specific versions of this publication, campus equity representatives were invited to add a section on their internal efforts beyond the previously described objectives and deliverables. Where appropriate, those reports are presented.
Key definitions
Health equity
Catholic Health defines health equity using the Centers for Disease Control and Prevention’s (CDC) definition: health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Catholic Health also ascribes to the CMS advancement of health equity actions including:
• Identify health disparities.
• Define specific and actionable goals for addressing any disparities identified.
• Prioritize populations and communities that are historically underserved.
• Establish and implement their organization’s health equity strategy.
• Determine what tools and resources their organization needs to implement its strategy.
• Monitor and evaluate progress in addressing health disparities.
Priority populations
Catholic Health serves a diverse population across Long Island. Our patients, who represent nationalities from all across the world, speak more than a dozen primary languages. In evaluating population health and demographics on Long Island, including race, ethnicity and language data, along with geography (see figures 1.1 – 1.3), Catholic Health’s equity strategy defines the system-wide priority population as those living in zip codes with the highest quartile of social vulnerability, as defined in the Social Vulnerability Index (SVI). The highest SVI quartile represents approximately 15% of our patient population and significant health disparities can be found when comparing the highest quartile to the rest of our patients (see figure 2.0).
Social vulnerability index (SVI)
The SVI is a database of the CDC and Agency for Toxic Substances and Disease Registry (ASTDR), which refers to “the resilience of communities (the ability to survive and thrive) when confronted by external stresses on human health.” There are 16 factors that are formulated into a geographic map of social vulnerability, including demographics (e.g., race and ethnicity, socioeconomics) and numerous SDOH (e.g., housing situation and transportation access).
REaL
The term REaL refers to data collected on race, ethnicity and preferred language. Appropriate collection of demographic data plays a key role in understanding health equity. Both CMS and the American Hospital Association (AHA) have published numerous points of information emphasizing the need to collect REaL. As explained by the AHA, “collecting and stratifying patient REaL data are crucial for hospitals and health systems to understand the populations they serve and to implement the appropriate interventions for improving quality of care.”
New York State 1115 Medicaid Waiver
New York State approved the 1115 Medicaid Waiver and the waiver period began on April 1, 2024. The Waiver period runs through March 31, 2027, but can be extended. New York State has chosen 9 Social Care Networks (SCN) to administrate the Waiver over 9 regions. The Health and Welfare Council of Long Island (HWCLI), longtime partners of Catholic Health, have been chosen as the Social Care Network of Long Island. Although the Operations Manual for the Waiver is currently pending, the main goal of the Waiver will be to address the SDOH in Medicaid patients, and connect them to ongoing social services through community based partners. The resulting improvement in health outcomes, and decrease in preventable downstream health care utilization are the long term justifications for the project. Catholic Health is actively preparing to evaluate ways to participate in the Waiver and ensure our patients and community have the best opportunities to achieve their maximal health outcomes.
Equity as the central theme of the Community Health Roadmap
In 2022, Catholic Health established a Community Health Roadmap, which incorporates health equity into every aspect. This roadmap describes specific objectives and action steps that will guide Catholic Health along the Health Equity journey. The specific pillars, objectives and system action steps to improve health equity are presented.
Pillars of community health on the equity journey
Organizational culture, systemic integration & education Catholic Health is working to incorporate an improved organizational culture of health equity system-wide. Educating more than 17,000 employees at Catholic Health on the tenets and practices of health equity was achieved through numerous in-service and educational objectives. Since starting the initiative in early 2023, more than 1,500 new employees have already been trained in the basics of health equity at system-wide new employee orientation. The Education subcommittee of the HELC is determining the best mandatory training for employees to understand implicit bias, structural racism and other important topics in health equity. Ongoing training, self-evaluation and quality improvement will ensure that Catholic Health successfully provides health equitable care. Other objectives and timelines within this pillar include:
• Curate internal listening sessions (Target Q2, 2024) (pending training of Health Equity Champions).
– Committee Reports presented at system-wide Quality Committee meetings, and are shared with Catholic Health Board of Directors (ONGOING).
• Identify a system equity leader (COMPLETED).
– Train and engage campus equity champions (Q4 2023 – Q4, 2024). Training Expected 2024 – 2025. See more under Catholic Health First Committee section.
• Ongoing Assessment, education, and re-education of all new Catholic Health employee regardless of job title receive health equity training at system orientation (ONGOING).
• Create leadership and mentorship opportunities for minority team members (ONGOING).
Mission & Equity
Data analytics and strategic planning
Equity programs must be based on appropriate collection, stratification and analysis of demographic and epidemiologic outcome data. It is imperative to improve the collection of REaL data to identify health disparities. Geographic data, whether it be census tract, or zip code data will be used to identify needs by community and help identify vital stakeholders and strategic initiatives to improve health disparities. Other objectives and timelines within this pillar include:
• Invest in epidemiology team (Q4, 2023)—Director of Epidemiology and Public Health Analytics hired May, 2024 (COMPLETED).
• Community events based on data and mission (ONGOING).
• Improve demographic data collection (Q4, 2023) (ONGOING, led by Director of Epidemiology).
• Measure linkage to care (Q4, 2024)—New timeline 2025 (ONGOING).
Figure 1.0
Community engagement/participation
Community member participation in their own health care will ultimately lead to improved outcomes. Access to care is a key component of achieving participation in care and outcome measures will be used to assess internal efforts at community engagement. Targeted community engagement based on statistical needs, health disparities and outcome measures ensures the tenet that we provide tailored services to individuals and communities. This aligns with our definition of health equity. Objectives and discreet action steps include:
• Recruit and train a multilingual, multicultural Speakers Bureau that can communicate in diverse communities regarding many of the most common health topics (Q4, 2023) (COMPLETED).Formal Speakers Bureau activated, 26 currently spoken languages.
• Joint Mission/Equity initiative through Parishes (ONGOING).
Telehealth Pilot—Began at St. Brigid’s, June, 2024.
– Pilot with Spanish-speaking residents.
– Engage both in the church and their health.
– Insurance enrollment where possible.
– Link all to preventive care.
• Listening sessions with community leaders (Q4, 2023) (COMPLETED, see Addendum).
– Identify unmet needs and improvement opportunities.
• Culturally and linguistically diverse recruitment at all levels (mirror patient populations) (ONGOING).
• Grow presence and scope of Community Health Workers (Began Q3) (ONGOING). Community Health Worker program for food insecurity has now extended to all 6 Emergency Departments. Goal is further expansion to achieve success in 1115 Medicaid Waiver.
• Leadership and advancement opportunities (ONGOING).
• Evaluate community events for results, use resources efficiently (ONGOING).
Social Determinants of Health (SDOH)
Catholic Health supports a strategy of “well care” over the more traditional “sick care” often offered by hospitals and hospital systems. In our model of well care, addressing the SDOH as a means of helping people stay healthy and out of the hospital is a guiding principal. More than 80% of a person’s health outcomes are not clinical, but rather, are based on the social drivers and influences in their lives, along with their genetics. While we cannot alter genetics, Catholic Health endeavors to improve the controllable social drivers that lead positively to health, and negatively to illness and diseases, often chronic in nature. To launch Catholic Health’s work in this realm, in 2022, we launched a food insecurity screening program in all 6 of our Emergency Departments (ED). The initiative consists of screening all patients
coming into the ED with the “Hunger Vital Signs,” published by the CDC. What differs this award-winning program from many others is that anybody who screens positive is provided with a “food-to-go bag” to ensure they do not go home to an empty kitchen. While that bag is only meant to cover food needs over the first couple of days post-discharge, social work teams spend those days addressing the social service need and ensuring ongoing food and nutrition services are implemented. Partnering with Community-Based Organizations (CBOs) is a vital component of achieving equity, and meeting the SDOH needs of our patients. Catholic Health has established strong relations with the Health and Welfare Council of Long Island (HWCLI), and many of the CBOs they represent. For example, this includes the food pantry “Long Island Cares,” who provides the food-to-go bags discussed above. Objectives to address the SDOH include:
• Create and implement system wide screening tool for SDOH to be added to patient care roadmap (Q4, 2023) (COMPLETED). The SDOH screening tool to be reconfigured for the 1115 waiver (ONGOING). NYSAHC tool to be implemented as Catholic Health Standard of Care.
• Train staff on asking and collecting SDOH data (Q4, 2023) 2024 – 25 objective to train in accordance with the requirements of the 1115 Medicaid Waiver screening process (ONGOING).
• Collaboration with Community Based Organizations (vital partners) (ONGOING).
• Use emerging technology/program to close the CBO communication loop (evaluation of existing products in progress) (ONGOING).
• Align ACO, community clinical partners (ONGOING).
• Food insecurity is a model program, grow “to-go bag” initiative (completed ). We plan to take this program to the next level, i.e., nutritionally appropriate prescription program (2025) (ONGOING).
• Emphasis on social workers role (ONGOING).
• Internal evaluation of efforts (ONGOING).
• Seek grants for community initiatives (ONGOING).
Quality and Patient Experience
Catholic Health values quality to the point that “there is no quality without equity!” As such, equity is to be treated with quality metrics and measures and performance is to be evaluated in an ongoing fashion. The HELC is establishing quality metrics and measures, staff is being trained and there will be a culture of accountability for the results. Ensuring that we meet our patients’ needs, including their cultural and religious needs, is paramount in our patient experience strategy. Factors such as communicating with patients in their preferred language, is an example of the intersection of equity, patient experience and quality. Outcomes are impacted by a patient’s comprehension of medical discussions.
The intersection of health equity and quality is so important that the formal reporting of the minutes of the HELC is part of the system-wide Quality Committee Meetings (a Board of Directors level meeting), and the HELC chair presents a report monthly on equity activities at the meetings. Equity objectives related to quality include:
• Equity report at QMC meetings(ONGOING). Minutes approved at QMC meeting.
• Follow AHA roadmap milestones (ONGOING).
• Train staff in cultural appropriateness and mandate trainings (2024) (ONGOING).
• Evaluate patient experience ratings for improvements (ONGOING).
• Utilize IT tools to assess Catholic Health and partner equity performance (Q1, 2024).
• Apply for “Health Care Equity Certification” when qualified (IN PREPARATION).
Regulatory requirements
Catholic Health diligently monitors updates, new procedures and reporting regulations from major oversight, regulatory and evaluative bodies, including but not limited to CMS, the Joint Commission and Leapfrog. Training staff in new rules and reporting requirements is embedded in equity metrics and training. Catholic Health strives to achieve the highest scores on reviews, meet all emerging measures and reporting requirements, and comply with new imperatives as it relates to health equity, health disparities, evaluation and any identified necessary corrective measures.
Health Equity Leadership Council (HELC)
Catholic Health has established a multi-disciplinary system-wide HELC to further the mission of Catholic Health and its affiliated entities. The Council shall champion and steward the system’s continued advancements in health equity for its patients, its patients, employees and the Long Island Community, in a manner consistent with the system’s responsibilities under state and federal law, and the Ethical and Religious Directives for Catholic Health Care Services as interpreted and applied by the Bishop of the Diocese of Rockville Centre.
Catholic Health defines “health equity” as being achieved when every person has a fair and just opportunity to attain his or her highest level of health. Specifically, Catholic Health is dedicated to ensuring, insofar as it depends on the system, that excellent health outcomes are available to every person who presents at one of the system’s facilities or physician practice locations, notwithstanding social, political, economic or other conditions that commonly result in and perpetuate injustice or inequity among individuals.
The six-pronged mission of the Council is as follows:
• Establish Catholic Health as the most trusted health care system on Long Island by its dedication to justice in the system’s delivery of health services.
• Align the system with its Catholic mission to reach and serve all communities, especially the most vulnerable, through the stewardship and deployment of its resources for the advancement of health equity.
• Increase, improve and leverage community relationships and partnerships to inspire, empower and sustain individuals to augment their health.
• Integrate consideration of health equity into all aspects of the system’s operations.
• Address and ameliorate SDOH to improve overall health outcomes and decrease unnecessary hospital admissions and readmissions.
• Meet emerging regulatory and industry requirements relative to health equity.
Catholic Health First Education
Long Live Long Island Quality & Data Analytics
Scope by Subcommittee
• Catholic Health First: Carry out the internal objectives of the Community and Public Health Equity Roadmap.
• Education: Address trainings, disseminate information and raise awareness of equity activities, system initiatives and regulatory.
• Long Live Long Island: Address community partnerships, patient engagement and social drivers.
• Quality and Data Analytics: Address screening tools, epidemiology, digital optimization for information collection and messaging.
Summary of year’s results by subcommittee
Catholic Heath First (Paul Stuart, Chair)
• Curate internal listening sessions (practice what we preach). We will develop a process following the establishment of campus champions.
• Establish campus equity champion network. The subcommittee evaluated the E-Cornell training program for Ethical and Religious Directives compliance, and found the program to be compliant. Catholic Health has committed to fund training for one representative from each campus per semester. Application process in development.
• Optimize internal operations to address equity gaps (i.e., access to care, child care and food insecurity). Planning currently in progress to evaluate need and options.
• Culturally and linguistically diverse recruitment at all levels (mirror patient populations) (ONGOING).
• Leadership and advancement opportunities (ONGOING).
• Establish the eCornell Diversity & Inclusion certificate program to establish and grow our campus equity champion network.
• Increase visibility, accessibility and utilization of existing Catholic Health programs and offerings that support the health and welfare of our workforce.
• Partner with the Long Live Long Island subcommittee to foster community relationships that support our recruitment strategy.
• Partner with the Center for Performance Excellence to increase awareness and utilization of existing Catholic Health programs and offerings that support career development and advancement.
Education subcommittee (Annmarie Smith, Chair)
• Develop a system-wide Equity Education Program with ongoing evaluation (i.e., re-education, compliance).
– Mandated trainings (i.e., implicit bias training)—New Implicit bias training implemented and mandated, launched April 2024.
– Explore GME curriculum—Health Equity training being incorporated into resident trainings via Good Samaritan University Hospital and system-wide.
• Activate Internal Speakers Bureau (equity education, system orientation speakers) (IN PROGRESS).
• Expand SDOH Education Module, Launched 2024.
• Launched Inclusive Leadership Workshop, 2024.
Future objectives, Education subcommittee
• Create on-demand library for Health Equity training—2025.
• Continue to track compliance of Unconscious Bias and SDOH Education Modules.
• Evaluate education modules and add new programs or update existing programs as needed.
• Evaluate compliance and provide support to employees and department leaders.
• Support the Catholic Health First subcommittee with the Health Equity Champions program.
• Increase internal capacity to improve the number of interpreters in the system (collaboration with other subcommittees).
• Awareness of policies related to what employees are allowed to do (e.g., cannot interpret for patients to sign consent, cannot interpret for diagnosis, treatment plans etc.).
• Include Health Equity in the GME Series and Excellence in Nursing Leadership Series.
• Create a mini-education library of previously recorded education modules (Catholic Health Academy).
Long
Live Long Island (Lisa Santeramo, Chair)
• Establish a Speakers Bureau (COMPLETED and ONGOING). Currently 26 languages able to be presented by Catholic Health Staff: Arabic, Bengali, Chinese, Creole, English, Filipino, French, German, Greek, Hindi, Italian, Korean, Malayalam, Mandarin, Polish, Portuguese, Punjabi, Romanian, Russian, Spanish, Tagalog, Tamil, Telugu, Turkish, Ukrainian and Urdu.
• Plan and execute community listening sessions (see Addendum for full report).
• Curate equity-specific community events based on data and mission (ONGOING).
• Collaboration with community-based organizations (CBO) (ONGOING).
• Seek community grants in alignment with key equity priorities (ONGOING).
Future objectives, Long Live Long Island subcommittee
• Continue to expand the established speakers bureau.
• CBO Partnerships:
– Utilizing the listening session data—identify potential community partners that will support our 1115 waiver and mission goals.
– Bandwidth analysis—establish internal mechanisms and processes to manage external partner relationships and address potential bandwidth challenges.
– Work with Catholic Health and the CBOs to establish formal partnerships to support our 1115 waiver and mission goals.
• Catholic Health Physician Partners (CHPP) and Independent Provider Association (IPA) synergy:
– Gap analysis in equity work—work with the CHPP & IPA to determine what they are already doing under the Catholic Health banner and create a gap analysis report with recommendations for alignment with Catholic Health system.
– Work with IT to do a data run and analysis on how and how much of our employed or IPA practices are billing for healthequity related services reimbursed by CMS in the 2024 physician fee schedule.
• Continue to expand external events that are equity focused.
• Continue to seek community grants in alignment with key equity priorities with a specific focus on expanding telehealth access within parishes and supporting key Community Outreach initiatives that support health equity.
Data
and Quality subcommittee (Monique Ford and Jason Tagliarino, Co-Chairs)
• Ongoing assessment of equity performance metrics (IN PROGRESS).
• Improve demographic data collection utilizing digital and AI resources, where appropriate.
• Establish and deploy system-wide screening tool to be added to patient care roadmap (COMPLETED), now being updated to meet screening requirements of the 1115 Medicaid Waiver.
• Develop equity quality metrics (create dashboard) (IN PROGRESS).
• Utilize IT tools to assess Catholic Health and partner equity performance.
• Employ emerging resources and technology (i.e., telehealth) to improve equity, quality and patient experience (IN PROGRESS).
Future objectives, Data and Quality subcommittee
• Ensure and expand to all service lines a system SDOH screening tool that meets state and federal regulatory requirements.
• Expand screenings to all patient facing interactions and implement digital facing self-service screening opportunities.
• Expand SDOH mandatory education to all Catholic Health employees.
• Develop a SDOH dashboard with stratification by unit and demographic information.
• Stratify patient experience data by demographic information with key improvement targets based upon patient’s preferred language.
Demographics of Catholic Health’s patients
The following data is based on patient encounters from January 1, 2023 to December 31, 2023.
Catholic Health’s patient population overview
Patient race
CHS System
Figure 1.1: Patient race for all patients 18 years and older who had an encounter in 2023 (N=578,517).
Source: Epic
Ethnicity
Figure 1.2: Patient ethnicity for all patients 18 years and older who had an encounter in 2023 (N=578,517).
Source: Epic
Preferred language
Figure 1.3: Preferred language for all patients 18 years and older who had an encounter in 2023 (N=578,517).
Source: Epic
2020 Social Vulnerability Index by Census Tract for Queens, Nassau and Suffolk
Figure 2.0: SVI by Census Tract for Catholic Health service areas.
Source: Epic
Identified system-wide health disparities
All disparities have been measured using Chi-square tests for statistical significance. All analyses were statistically significant. All data were obtained through Epic and include all patients with any encounter in the Catholic Health System from January 1 to December 31, 2023. Patients who died during or prior to 2023 were excluded from the sample. Age was calculated based upon each patients’ date of birth.
Race and ethnicity follow the Office of Management and Budget (OMB) federal race and ethnicity standard classifications. These are standard definitions provided by OMB to promote uniformity and
comparability for race and ethnicity data. These categories are used in the decennial census, household surveys, administrative forms and medical/public health research.
Preferred language was categorized as English, Spanish or other languages from the patient’s last stored value during 2023. Language data was disaggregated by our top two languages to facilitate visualization and statistical analyses. Stratification by preferred language does not include changes in self-reported preferred language.
Body Mass Index (BMI)
Table 1.1:
Percent of patients
18 years and older with a BMI >25 by 2020 SVI
Source: Epic
Table 1.2: Percent of patients 18 years and older with a BMI≥25 by race Source: Epic
Table 1.3: Percent of patients 18 years and older with a BMI ≥25 by ethnicity Source: Epic
Table 1.4: Percent of patients 18 years and older with a BMI ≥25 by preferred language
Breast Cancer screening
Breast cancer screening was defined as a patient having a breast cancer screening or mammography marked as completed from January 1, 2022 to December 31, 2023 for all women for all encounters in 2023.
Table 2.1: Percent of patients
40– 75 years with a Breast Cancer screening by SVI
Figure 3.2 – Source: Epic
Table 2.2: Percent of patients 40 – 75 years with a Breast Cancer screening by race Source: Epic
Table 2.3: Percent of patients 40 – 75 years with a Breast Cancer screening by ethnicity Source: Epic
Table 2.4: Percent
Primary Care Physician
Having a PCP was defined as having a health care provided documented in the electronic health record during 2023.
Table 3.1: Percent of patients 18 years and older with a PCP by SVI
Source: Epic
Table 3.2: Percent of patients 18 years and older with a PCP by race Source: Epic
Table 3.3: Percent of patients 18 years and older with a PCP by ethnicity Source:
Table 3.4: Percent of patients 18 years and older with a PCP by preferred language Source: Epic
Flu vaccine
Influenza vaccination is defined as all patients who received an influenza vaccination from January 1 to December 31, 2023. Influenza vaccination was defined through self-reported vaccination outside of Catholic Health and documentation of influenza vaccination administered in the electronic health record. Patients who were contraindicated for the flu vaccine were excluded. Contraindication was defined as hypersensitivity to eggs/thimerosal, had a prior negative reaction to a vaccination, had a bone marrow transplant within the last six months and had a history of Guillain-Barre syndrome. Patients who refused to receive a flu vaccination and did not receive a vaccination at another encounter were excluded.
Table 4.1:
Percent of patients 60 years and older with an influenza vaccination by SVI
Source: Epic
Table 4.2: Percent of patients 60 years and older with an influenza vaccination by race Source: Epic
Table 4.3: Percent of patients 60 years and older with an influenza vaccination by ethnicity Source: Epic
Table 4.4: Percent of patients 60 years and older with an influenza vaccination by preferred language Source: Epic
Annual Wellness Visit (AWV) or Physical Examination
Annual Wellness Visit or physical examination was measured by ICD codes related to an AWV or physical examination documented as visit diagnosis, billing diagnosis or on the patient’s problem list during 2023. If a patient had an ICD code documented during 2023, they were marked as “yes” having an AWV or physical exam during the 2023 year.
Table 5.1:
Percent of patients 18 years and older with an annual wellness visit or physical exam by SVI
Source: Epic
Table 5.2: Percent of patients 18 years and older with an annual wellness visit or physical exam by race Source: Epic
Table 5.3: Percent of patients 18 years and older with an annual wellness visit or physical exam by ethnicity
Table 5.4: Percent of patients 18 years and older with an annual wellness visit or physical exam by preferred language Source:
Good Samaritan University Hospital Health Equity Strategic Plan
A note from the President
Dear Colleagues,
Catholic Health defines health equity using the Centers for Disease Control and Prevention’s (CDC) definition—the state in which everyone has a fair and just opportunity to attain their highest level of health. As a faith-based institution, Good Samaritan University Hospital, the flagship for Catholic Health in Suffolk County, has a long standing tradition of community outreach and support to areas that are underserved, have a high level of social determinants of health (SDOH) and historically, have barriers to accessing quality health care. This has been accomplished through direct outreach programs within areas of uninsured and underinsured residents, programs held local to the hospital, as well as collaborating with other not-for-profit organizations, municipalities and governmental agencies with similar goals. By providing a high level of education, robust screenings and vaccinations, Good Samaritan continues to impact the lives of all throughout the south shore of Suffolk County, bringing the theory of health equity to realization.
By identifying health disparities within various regions of Suffolk County, Good Samaritan’s Public & Community Relations Department is able to evaluate and assess the services needed for specific populations. Understanding that needs may vary between communities, Good Samaritan works closely with partners such as the Nassau-Suffolk Hospital Council, Suffolk County Department of Health and the Towns of Islip and Babylon to develop data-driven strategies and programs. One highlight of these partnerships was the hospital’s response to the COVID-19 pandemic. Good Samaritan provided both testing and vaccinations within the hamlet of Brentwood, one of the largest hamlets in New York State with more than 65,000 residents, many of whom are identified as being under the poverty-level. During the pandemic, Brentwood was a concentrated area of COVID positive residents, due to lack of access to health care, education and cultural differences from surrounding zip codes. Working with New York State and the Town of Islip at two different clinical locations, Good Samaritan assisted in providing nearly 80,000 residents with COVID testing, vaccinations and education in both English and Spanish.
Since the pandemic, Good Samaritan has continued to embed itself within the community, regularly hosting screening, education and vaccination events to communities of all needs and resources, with the goal of equal access to health care services for all. Physicians, nurses and support staff consistently volunteer their time and skills to help those in need, many of whom are their neighbors, family and friends. Through this outreach, we work together as one community to come ever closer to our goal of health equity for all.
Sincerely,
Justin Lundbye, MD, MBA, FACHE President, Good Samaritan University Hospital
Good Samaritan University Hospital Health Equity Activities
In your community 2024
Good Samaritan University Hospital has a consistent focus on caring for its communities and local residents. It is the foundation of the hospital, named after the well know biblical story of a samaritan providing assistance to an unknown traveler. Many who work at Good Samaritan also live in the area and take pride in helping their “neighbors,” many of whom are in need and have a lack of access to health care services. Through the hospital’s Public & Community Relations Department, both clinical and non-clinical staff are able to provide their time to assist at a number of events, lectures, educational symposiums, screenings, vaccination clinics and more. The goal is to reduce the barriers in accessing health care for all.
With the goal of intervening in areas that are identified as being impacted by high levels of SDOH, Good Samaritan focused on increasing flu vaccinations, breast screenings and educating patients without a primary care physician for its 2024 strategy plan. To impact these metrics, resources and efforts were shifted to allow for more screenings, vaccination clinics and events.
Historically, Good Samaritan provided two to three vaccination events related to influenza in the local community, often partnering with local municipalities. In 2024, to intervene in the identified issue, Good Samaritan has already scheduled six flu shot clinics located throughout the hospital’s service area, with a focus on underserved communities. More clinics are being identified and will be scheduled through the end of 2024 and early 2025.
Good Samaritan was ground zero in the battle against breast cancer, being the location of one of the first mapping projects and identified cancer clusters in the United States. With an offsite Women’s Imaging Center, a robust Breast Health Center and strong
partnerships with local breast cancer coalitions, the hospital has been an early mover in providing the highest level of breast health care. This continues into the community outreach space, where historically two open house breast screening events were held annually. In 2024, this was increased to four events and also included access to transportation through Uber Health for those who faced this social determinant. This service, though, went underutilized due to compliance issues in promoting transportation provided by the hospital to the public. Those without insurance were provided their screening through our partnership with the Cancer Services Program of Western Suffolk. Any patients found to have a positive test result were then paired with appropriate resources. Additional events focused on breast health education and early detection were also held with more being scheduled through the remainder of the year.
Good Samaritan treats more than 90,000 patients annually through its Emergency Department, which features a verified adult and pediatric trauma center, separate pediatric emergency department, a Geriatric Fracture Program and was recently recognized as a Geriatric Emergency department. It provides connections to high level hospital services including the Gary H. Richard and Family Stroke & Brain Aneurysm Center of Long Island and St. Francis Heart Center. Many of those who come through the Emergency Department doors are uninsured or underinsured and use this department as their source of primary care. During intake, patients are asked if they have a primary care physician, and if not, are provided a referral for one. As an extension of this, Good Samaritan has developed a flyer that includes a focus on primary care providers and promotes those locations at all events within its service area. This allows for direct education on primary care providers local to the resident, in their community.
Good Samaritan University Hospital patient population overview
The following data were obtained from Epic and includes all patients who had an encounter with Good Samaritan University Hospital from January 1 to December 31, 2023. Patents are only included in the sample once, even if they had more than one encounter with Catholic Health. Patients who died during or prior to 2023 were excluded from the sample.
GSUH
Patient race
Figure 3.1: Patient race for all patients 18 years and older who had an encounter in 2023 (N=104,709)
Source: Epic
Ethnicity
Figure 3.2: Patient ethnicity for all patients 18 years and older who had an encounter in 2023 (N=104,709)
Source: Epic
Preferred language
Figure 3.3: Preferred language for all patients 18 years and older who had an encounter in 2023 (N=101,706).
Source: Epic
SVI
by
Census Tract for
Good Samaritan University Hospital service areas
Figure 4.0: SVI by Census Tract for Good Samaritan University Hospital service areas.
Source: Epic
Good Samaritan University Hospital identified health disparities
All disparities have been measured using Chi-square tests for statistical significance. All analyses were statistically significant. All data were obtained through Epic and include all patients with any encounter at Good Samaritan University Hospital from January 1 to December 31, 2023. Patients who died during or prior to 2023 were excluded from the sample. Age was calculated based upon each patients’ date of birth.
Race and ethnicity follow the Office of Management and Budget (OMB) federal race and ethnicity standard classifications. These are standard definitions provided by OMB to promote uniformity
Body Mass Index (BMI)
Table 6.1.1:
Percent of patients 18 years and older with a BMI ≥25 by 2020 SVI
Source: Epic
and comparability for race and ethnicity data. These categories are used in the decennial census, household surveys, administrative forms and medical/public health research.
Preferred language was categorized as English, Spanish or other languages from the patient’s last stored value during 2023. Language data was disaggregated by our top two languages to facilitate visualization and statistical analyses. Stratification by preferred language does not include changes in self-reported preferred language.
6.1.2: Percent of patients 18 years and older with a BMI ≥25 by race
Source: Epic
Table 6.1.3: Percent of patients 18 years and older with a BMI ≥25 by ethnicity Source:
Table 6.1.4: Percent of patients 18 years and older with a BMI ≥25 by preferred language Source:
Table
Breast Cancer screening
Breast cancer screening was defined as a patient having a breast cancer screening or mammography marked as completed from January 1, 2022 to December 31, 2023 for all women for all encounters in 2023.
Table 6.2.1: Percent of patients 40 – 75 years with a Breast Cancer screening by SVI
Source: Epic SVI overall
(zip code)
Table 6.2.2: Percent of patients 40 – 75 years with a Breast Cancer screening by race Source: Epic
Table 6.2.3: Percent of patients 40 – 75 years with a Breast Cancer screening by ethnicity Source:
Table 6.2.4: Percent of patients 40 – 75 years with a Breast Cancer screening by language Source: Epic
Language
Primary Care Physician (PCP)
Having a PCP was defined as having a health care provided documented in the electronic health record during 2023.
Table 6.3.1: Percent of patients 18 years and older with a PCP by SVI Source: Epic
Table 6.3.2: Percent of patients 18 years and older with a PCP by race Source: Epic
Table 6.3.3: Percent of patients 18 years and older with a PCP by ethnicity Source: Epic
Table 6.3.4: Percent of patients 18 years and older with a PCP by preferred language Source: Epic
Flu vaccine
Influenza vaccination is defined as all patients who received an influenza vaccination from January 1 to December 31, 2023. Influenza vaccination was defined through self-reported vaccination outside of Catholic Health and documentation of influenza vaccination administered in the electronic health record. Patients who were contraindicated for the flu vaccine were excluded. Contraindication was defined as hypersensitivity to eggs/thimerosal, had a prior negative reaction to a vaccination, had a bone marrow transplant within the last six months and had a history of Guillain-Barre syndrome. Patients who refused to receive a flu vaccination and did not receive a vaccination at another encounter were excluded.
Table 6.4.1:
Percent of patients
60 years and older with an influenza vaccination by SVI
Source: Epic
Table 6.4.2: Percent of patients 60 years and older with an influenza vaccination by race Source: Epic
Table 6.4.3: Percent of patients 60 years and older with an influenza vaccination by ethnicity Source: Epic
Table 6.4.4: Percent of patients 60 years and older with an influenza vaccination by preferred language Source: Epic
Language
Annual Wellness Visit (AWV) or physical examination
Annual Wellness Visit or physical examination was measured by ICD codes related to an AWV or physical examination documented as visit diagnosis, billing diagnosis or on the patient’s problem list during 2023. If a patient had an ICD code documented during 2023, they were marked as “yes” having an AWV or physical exam during the 2023 year.
Table 6.5.1:
Percent of patients 18 years and older with an annual wellness visit or physical exam by SVI
Source: Epic
Table 6.5.2: Percent of patients 18 years and older with an
visit or physical exam by race Source: Epic
physical exam with AWV/ physical exam
Table 6.5.3: Percent of patients 18 years and older with an annual wellness visit or physical exam by ethnicity Source: Epic OMB Ethnicity Not Hispanic/Latino
Table 6.5.4: Percent of patients 18 years and older with an annual wellness visit or physical exam by preferred language Source: Epic
Language English Spanish Other languages Measures
patients with AWV/ physical exam # patients with AWV/ physical exam
patients with AWV/ physical exam
patients with AWV/ physical exam
patients with AWV/ physical exam
patients with AWV/ physical exam
Market-specific priority population Equity Action Plan for Good Samaritan University Hospital
Below, please find the health disparities the hospital will focus on improving, including the discreet action steps that will be tracked to close the identified gap.
Health disparity: % patients with flu vaccine 60+
Identified intervention
• Increase in flu shot Clinics in strategic locations
Owner
• Public & Community Relations
Key stakeholders
• Underserved community members who are highly vulnerable in target communities: Brentwood, Bay Shore and Central Islip
Key milestones
• September: Brentwood Flu Clinic
• October: Senior Center Flu Clinics/TOI Employee Flu Clinic
• November: Other targeted Senior Centers
• February: Bay Shore Mall
Timeline to completion
• January 2026
Resources
• Administration, Pharmacy (vaccine), Public & Community Relations (promotions), Volunteer Clinicians, local partners
Measures of success
• Goal: 5% increase in flu shots in highly vulnerable populations
• Reach: 8% increase in highly vulnerable populations
Health disparity: % patients with no PCP
Identified intervention
• Increase referrals to PCP from the emergency medicine population
Owner
• Patient Access, Care Managers
Key stakeholders
• Underserved community members who are highly vulnerable in target communities: Brentwood, Bay Shore and Central Islip
Key milestones
• ED, Inpatient, Diabetes Education Center and PCP encounter
Timeline to completion
• January 2026
Resources
• Patient Access, Emergency Dept Staff, Catholic Health Central Referral Office (CRO), Public & Community Relations (promotions), local partners
Measures of success
• Goal: 5% increase in flu shots in highly vulnerable populations
• Reach: 8% increase in highly vulnerable populations
Health disparity: % patients with breast cancer screening
Identified intervention
• Increasing the number of patients who have a breast screening through increased screening events and promotion to targeted stakeholders
Owner
• Patient Access, Care Managers
Key stakeholders
• Underserved community members who are highly vulnerable in target communities: Brentwood, Bay Shore and Central Islip
Key milestones
• May: Women's Health events; Mothers Day
• October: Breast Health Awareness Month
• Additional screening events in subsequent months
Timeline to completion
• January 2026
Resources
• Women’s Imaging Center, Public & Community Relations (promotions), local partners
Measures of success
• Goal: 5% increase in flu shots in highly vulnerable populations
• Reach: 8% increase in highly vulnerable populations
Mercy Hospital Health Equity Strategic Plan
A note from the President
Dear Colleagues,
Welcome to Mercy Hospital. As the President of Mercy Hospital, it is my honor to welcome you to a community deeply committed to providing exceptional health care while placing diversity, equity and inclusion (DEI) at the core of everything we do. At Mercy, we recognize that our strength lies in the diversity of our patients, staff, and the community we serve, and we are dedicated to fostering an inclusive environment where everyone feels valued, respected and cared for.
We are committed to ensuring that every individual who walks through our doors receives compassionate, high-quality care that is equitable and tailored to their needs. This commitment to health equity is evident in our daily practices and the initiatives we champion. We continually monitor and address health care disparities through disparity-driven quality improvement, such as enhancing primary care access, flu vaccinations and routine health screenings. These efforts are aimed at identifying and closing gaps in care, especially for underserved populations.
Mercy also integrates social determinants of health (SDOH) assessments into patient care to address factors like housing, food security and employment, which significantly impact health outcomes. Our approach ensures that patients needing additional support are connected with resources and follow-up actions to improve their overall well-being.
Our commitment to DEI extends to our workforce as well. We are focused on building a diverse and inclusive staff that mirrors the community we serve, from front-line employees to leadership positions. By promoting diversity in our workforce, we ensure that our caregivers are both reflective of and responsive to the diverse needs of our patients.
At Mercy Hospital, we are not only a place for healing but also a beacon of progress, dedicated to promoting health equity and creating a more inclusive future for all. We are proud of our role in advancing these goals and we look forward to working together to continue making a positive impact on the lives of those we serve.
Sincerely,
Joseph Manopella President, Mercy Hospital
Mercy Hospital Diversity, Equity & Inclusion Committee Charter
Mission Statement
The Mercy Hospital Diversity, Equity & Inclusion Committee (DEIC) is dedicated to fostering a culture of inclusivity, diversity and equity within the hospital. Our mission is to ensure equitable access to care, improve patient experiences, enhance workforce diversity and promote an inclusive environment for both staff and patients. Through collaborative efforts, we aim to identify, address and reduce disparities in health care outcomes and workplace experiences, ensuring that Mercy Hospital is a place where diversity is celebrated, and all individuals feel valued and respected.
Vision
Our vision is a hospital community that embodies diversity, equity, and inclusion (DEI) in all aspects of its operations, from patient care to employment practices. We envision Mercy Hospital as a leader in providing equitable health care, fostering a diverse and inclusive workforce and setting a standard for DEI excellence in the health care industry.
Equity domains and objectives
Disparity driven quality improvement & social determinant of health screening.
Objective: Regularly monitor and analyze quality metrics related to disparities in patient care, focusing on primary care physician (PCP) follow-up, flu vaccine uptake and annual physicals for patients engaging in health care with Mercy Hospital.
Strategies: Implement targeted interventions to address identified disparities, engage in continuous quality improvement processes and report progress to stakeholders. Engage team in DEI education and SDOH impact on patient care/outcomes.
Measures outcomes: 1) Audit compliance of quality metrics in addition to SDOH screening tool, 2) Track/trend the number of screen positive patients that receive referrals and action items, 3) Identify and address opportunities for improvement in disparity metrics.
Patient Experience
Objective: Assess and improve patient experiences by trending patient experience (PX) data based on demographics to identify disparities.
Strategies: Develop and implement strategies to enhance patient satisfaction and experience, especially among marginalized groups, through customized care approaches and patient engagement initiatives.
Measured Outcomes: 1) Track/trend demographic data in correlation with PX scores, 2) Analyze the use of translator/ language assistance for non-English speaking patients.
Strategies: Provide ongoing training and support for staff on the SDOH tool, integrate SDOH assessments into patient care plans and monitor the impact on patient outcomes.
Human Resources
Objective: 1) Monitor trends in staff diversity and inclusivity, ensuring that Mercy Hospital’s workforce reflects the diversity of the community it serves, 2) Promote and retain diversity in front-line employees and leadership positions that mirror the patient population of Mercy Hospital.
Strategies: Implement recruitment, retention and professional development practices that prioritize diversity and inclusion, conduct regular assessments of workplace culture and address barriers to inclusivity.
Structure and membership
The DEIC will consist of members from various departments within Mercy Hospital, including but not limited to patient care, administration, HR and community outreach. Membership will be diverse in terms of professional background, race, ethnicity, gender and other characteristics to ensure a wide range of perspectives.
Meetings and communication
Small group subcommittees will conduct analysis of the selected equity domains. Each committee will meet monthly to review progress, discuss new initiatives and address challenges. The large DEI committee will meet on a bi-annual basis to conduct small group report out and large group discussions. Each small group is responsible for designing and implementation of performance improvement (PI) processes in each domain.
Accountability and reporting structure of the committee
The DEIC will report directly to the hospital’s performance improvement patient safety committee. An annual report summarizing progress, challenges and future plans will be provided to all stakeholders, including hospital staff, patients and the community. Ongoing education and outcomes will be periodically disseminated to in the Mercy Hospital monthly meetings.
DEIC PI Projects 2023 – 2025
Project #1:
Analyze disparities as it relates to annual wellness exams
Overview: Our aim is to increase the number of patients who complete their annual physical examinations. Mercy Hospital has appointed our Primary Care Physician Champions in the Family Care Center to charge the initiative on creating a streamline communication process for achieving compliance with annual wellness visits.
Project #2
Action plans: Electronic reminders are sent to patients, notifying them of upcoming appointments, vaccination requirements, annual wellness examinations and permitting pre-registration.
Assignment of a Primary Care Provider during acute hospitalization
Overview: Mercy Hospital has appointed a physician champion and Chief of Family Medicine to function in the capacity of the key liaison between inpatient and outpatient care. The physician champion will charge an initiate to create a referral stream for patients to follow up in the Family Care Center after acute inpatient stay.
Project #3
Action plans: Hospitalists are contacting the outpatient Family Care Center for warm handoff and set up of follow up appointments. We have also expanded out specialist access to this initiative to enhance our referrals.
Measured outcomes:
1. We will measure the no-show rate, and 2. Appointment creation via SMS push rate before and after interventions. Additionally, we will also measure the increase in visit volume to assigned providers.
Measured outcomes:
1. We will measure the rate increase in referral traffic (inbound and outbound), and
2. Rate of ER utilization for extremely low acuity issues. We anticipate an increase in referrals to the clinic and decrease in Emergency Room utilization.
Improving Influenza Vaccination Rates in the Mercy Hospital Primary Care Clinic
Overview: Our aim is to increase the number of patients who complete their annual influenza vaccinations. Mercy Hospital has appointed our Primary Care Physician Champions in the Family Care Center to charge the initiative on creating a streamline communication process for achieving compliance with annual wellness visits.
Action plans: Electronic reminders are sent to patients, notifying them of upcoming appointments, vaccination requirements, annual wellness examinations and permitting pre-registration. We will also update our community event calendar published with influenza pod dates.
Measured outcomes: We will measure the number of influenza vaccines given during the course of influenza season in comparison to prior years.
Mercy Hospital patient population overview
The following data were obtained from Epic and includes all patients who had an encounter with Mercy Hospital from January 1 to December 31, 2023. Patents are only included in the sample once, even if they had more than one encounter with Catholic Health. Patients who died during or prior to 2023 were excluded from the sample.
Patient race
Figure 5.1: Patient race for all patients 18 years and older who had an encounter in 2023 (N=45,926).
Source: Epic
Ethnicity
Figure 5.2: Patient ethnicity for all patients 18 years and older who had an encounter in 2023 (N=45,926).
Source: Epic
Preferred language
Figure 5.3: Preferred language for all patients 18 years and older who had an encounter in 2023 (N=45,926).
Source: Epic
Social Vulnerability Index by Census Tract for Mercy Hospital service areas
Figure 6.0: SVI by Census Tract for Mercy Hospital service areas.
Source: Epic
Mercy Hospital identified health disparities
All disparities have been measured using Chi-square tests for statistical significance. All analyses were statistically significant. All data were obtained through Epic and include all patients with any encounter at Mercy Hospital from January 1 to December 31, 2023. Patients who died during or prior to 2023 were excluded from the sample. Age was calculated based upon each patients’ date of birth.
Race and ethnicity follow the Office of Management and Budget (OMB) federal race and ethnicity standard classifications. These are standard definitions provided by OMB to promote uniformity
Body Mass Index (BMI)
7.1.1:
Percent of patients 18 years and older with a BMI ≥25 by 2020 SVI
Source: Epic
and comparability for race and ethnicity data. These categories are used in the decennial census, household surveys, administrative forms and medical/public health research.
Preferred language was categorized as English, Spanish or other languages from the patient’s last stored value during 2023. Language data was disaggregated by our top two languages to facilitate visualization and statistical analyses. Stratification by preferred language does not include changes in self-reported preferred language.
Table 7.1.3: Percent of patients 18 years and older with a BMI ≥25 by ethnicity Source: Epic
Table 7.1.4: Percent of patients 18 years and older with a BMI ≥25 by preferred language Source: Epic
Table
Table 7.1.2: Percent of patients 18 years and older with a BMI ≥25 by race Source: Epic
Breast Cancer screening
Breast cancer screening was defined as a patient having a breast cancer screening or mammography marked as completed from January 1, 2022 to December 31, 2023 for all women for all encounters in 2023.
Table 7.2.1:
Percent of patients
40 – 75 years with a Breast Cancer screening by SVI
Source: Epic SVI overall percentile (zip code)
Table 7.2.2: Percent of patients 40 – 75 years with a Breast Cancer screening by race Source: Epic
Table 7.2.3: Percent of patients 40 – 75 years with a Breast Cancer screening by ethnicity Source:
Table 7.2.4: Percent of patients 40 – 75 years with a Breast Cancer screening by language Source: Epic Language English
Primary Care Physician (PCP)
Having a PCP was defined as having a health care provided documented in the electronic health record during 2023.
Table 7.3.1: Percent of patients 18 years and older with a PCP by SVI
Source: Epic
Table 7.3.2: Percent of patients 18 years and older with a PCP by race Source: Epic
Table 7.3.3: Percent of patients 18 years and older with a PCP by ethnicity Source: Epic
Table 7.3.4: Percent of patients 18 years and older with a PCP by preferred language Source: Epic
Flu vaccine
Influenza vaccination is defined as all patients who received an influenza vaccination from January 1 to December 31, 2023. Influenza vaccination was defined through self-reported vaccination outside of Catholic Health and documentation of influenza vaccination administered in the electronic health record. Patients who were contraindicated for the flu vaccine were excluded. Contraindication was defined as hypersensitivity to eggs/thimerosal, had a prior negative reaction to a vaccination, had a bone marrow transplant within the last six months and had a history of Guillain-Barre syndrome. Patients who refused to receive a flu vaccination and did not receive a vaccination at another encounter were excluded.
Table 7.4.1: Percent of patients
60 years and older with an influenza vaccination by SVI
Source: Epic
Table 7.4.2: Percent of patients 60 years and older with an influenza vaccination by race Source: Epic
OMB
Table 7.4.3: Percent of patients 60 years and older with an influenza vaccination by ethnicity Source: Epic OMB Ethnicity Not Hispanic/Latino Hispanic/Latino No answer/unknown
Table 7.4.4: Percent of patients 60 years and older with an influenza vaccination by preferred language Source: Epic
Language English Spanish Other languages
Annual Wellness Visit (AWV) or physical examination
Annual Wellness Visit or physical examination was measured by ICD codes related to an AWV or physical examination documented as visit diagnosis, billing diagnosis or on the patient’s problem list during 2023. If a patient had an ICD code documented during 2023, they were marked as “yes” having an AWV or physical exam during the 2023 year.
Table 7.5.1:
Percent of patients 18 years and older with an annual wellness visit or physical exam by SVI
Source: Epic
Table 7.5.2: Percent of patients 18 years and older with an annual wellness visit or physical exam by race Source: Epic
exam with AWV/ physical exam
Table 7.5.3: Percent of patients 18 years and older with an annual wellness visit or physical exam by ethnicity Source: Epic OMB Ethnicity Not Hispanic/Latino Hispanic/Latino No answer/unknown Measures
Table 7.5.4: Percent of patients 18 years and older with an annual wellness visit or physical exam by preferred language Source: Epic
Language English Spanish
Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
patients with AWV/ physical exam # patients with AWV/ physical exam
Other languages
physical exam
Mercy Hospital
Market-specific priority population Equity Action Plan for Mercy Hospital
Below, please find the health disparities the hospital will focus on improving, including the discreet action steps that will be tracked to close the identified gap.
Health disparity: Annual wellness examinations
Identified intervention
• Electronic Notifications
Owner
• Catholic Health DTS Brian Massari
Key stakeholders
• Catholic Health DTS
• Mercy Hospital
Key milestones
• Electronic reminders will be sent to patients, notifying them of upcoming appointments, vaccination requirements, annual wellness examinations and permitting pre-registration
Timeline to completion
• Q4 2024
Identified intervention
• Payer Partnerships
Owner
• Jeanine Cappello
• Chris Cells
Key stakeholders
• Mercy Hospital
• Managed Care Providers
Key milestones
• Healthfirst has dedicated office space in the Family Care Center to perform re-enrollments and assist patients whose Medicaid coverage has lapsed
Timeline to completion
• Rolling Resources
• Technology Resources
Measures of success
• No-show rates
• Appointment creation via SMS push
Health disparity: Influenza vaccination rates
Identified Intervention
• Electronic Notifications
Owner
• Catholic Health DTS Brian Massari
Key stakeholders
• Catholic Health DTS
• Mercy Hospital
Key milestones
• Electronic reminders will be sent to patients, notifying them of upcoming appointments, vaccination requirements, annual wellness examinations and permitting pre-registration
Timeline to completion
• Q4 2024
• Office Space
Measures of success
• Increase in visit volume to assigned providers
Identified Intervention
• Community Events
Owner
• Elizabeth Schwind
Key stakeholders
• Community Outreach
Key milestones
• Community event calendar published with influenza pod dates
Timeline to completion
• Rolling Resources
• Technology Resources
Measures of success
• No-show rates
• Appointment creation via SMS push
• People
Measures of success
• Number of vaccinations given. (Note these are tracked manually, a process is needed to get these into our electronic health record.)
Health disparity: Assigned Primary Care Provider
Identified intervention
• Payer Partnerships
Owner
• Jeanine Cappello
• Chris Cells
Key stakeholders
• Mercy Hospital
• Managed Care Providers
Key milestones
• Healthfirst has dedicated office space in the Family Care Center to perform re-enrollments and assist patients whose Medicaid coverage has lapsed
Identified intervention
• FQHC Alignment
Owner
• Chris Cells
Timeline to completion
• Rolling
Resources
• Office Space
Measures of success
• Reduction in lapsed Medicaid coverage (as noted by payer)
• Increase in visit volume to assigned providers
Key stakeholders
• Mercy Hospital
• Harmony Health care
Key milestones
• Specialist access started (Q1 2023)— Endocrinology
• Increase in referral traffic (inbound and outbound
• Decrease in ER utilization for extremely low acuity issues
Identified intervention
• Parish Telehealth Initiative
Owner
• Christine Hendricks
• Dr. Lawrence Eisenstein
• Chris Cells
Key stakeholders
• Catholic Health
• Diocese of Rockville Centre
Key milestones
• Pilot program initiated at St. Brigid’s Parish (Q2 2024)
Timeline to completion
• Rolling
Resources
• Technology
• Physician Assignment
• Care Management
Measures of success
• Service Utilization
St. Catherine of Siena Hospital Health Equity Strategic Plan
A note from the President
Dear Colleagues,
Part of our mission at Catholic Health is to have a comprehensive plan to enhance Health Equity across Long Island, serving those who are underserved and uninsured. At St. Catherine of Siena Hospital, we are committed to fulfilling this mission by identifying social determinants of health (SDOH) in the communities we serve and subsequently, implement an all-encompassing community outreach program to address economic and social obstacles.
Sadly, there are many who suffer from a disproportionate amount of preventable diseases. To address this concern, we are fully committed to providing access to primary care, as well as offer a wide variety of free health screenings, evidence-based health improvement programs and flu vaccinations in underserved and uninsured populations.
All patients who come to St. Catherine of Siena Hospital for medical care are offered services regardless of their ability to pay.
Many thanks to all of you for your unwavering support in helping us fulfill our mission to make sure that everyone in our communities has the same access to high-quality medical care. We will continue to make this a priority and we remain dedicated to eliminating health disparities in the communities we serve. Together, we can make a difference!
Sincerely,
Declan Doyle President, St. Catherine of Siena Hospital
St. Catherine of Siena Hospital patient population overview
The following data were obtained from Epic and includes all patients who had an encounter with St. Catherine of Siena Hospital from January 1 to December 31, 2023. Patents are only included in the sample once, even if they had more than one encounter with Catholic Health. Patients who died during or prior to 2023 were excluded from the sample.
Patient race
Figure 7.1: Patient race for all patients 18 years and older who had an encounter in 2023 (N=30,273).
Source: Epic
Ethnicity
Figure 7.2: Patient ethnicity for all Patients 18 years and older who had an encounter in 2023 (N=30,273)
Source: Epic
Preferred language
Figure 7.3: Preferred language for all patients 18 years and older who had an encounter in 2023 (N=30,273)
Source: Epic
Social Vulnerability Index by Census Tract for St. Catherine of Siena Hospital service areas
Figure 8.0: SVI by Census Tract for St. Catherine of Siena Hospital service areas.
Source: Epic
St. Catherine of Siena Hospital identified health disparities
All disparities have been measured using Chi-square tests for statistical significance. All analyses were statistically significant. All data were obtained through Epic and include all patients with any encounter at St. Catherine of Siena Hospital from January 1 to December 31, 2023. Patients who died during or prior to 2023 were excluded from the sample. Age was calculated based upon each patients’ date of birth.
Race and ethnicity follow the Office of Management and Budget (OMB) federal race and ethnicity standard classifications. These are standard definitions provided by OMB to promote uniformity
Body Mass Index (BMI)
Table 8.1.1:
Percent of patients 18 years and older with a BMI ≥25 by 2020 SVI
Source: Epic
and comparability for race and ethnicity data. These categories are used in the decennial census, household surveys, administrative forms and medical/public health research.
Preferred language was categorized as English, Spanish or other languages from the patient’s last stored value during 2023. Language data was disaggregated by our top two languages to facilitate visualization and statistical analyses. Stratification by preferred language does not include changes in self-reported preferred language.
8.1.2: Percent of patients 18 years and older with a BMI ≥25 by race
Source: Epic
Table 8.1.3: Percent of patients 18 years and older with a BMI ≥25 by ethnicity Source:
Table 8.1.4: Percent of patients 18 years and older with a BMI ≥25 by preferred language Source:
Table
St. Catherine of
Breast Cancer screening
Breast cancer screening was defined as a patient having a breast cancer screening or mammography marked as completed from January 1, 2022 to December 31, 2023 for all women for all encounters in 2023.
Table 8.2.1: Percent of patients 40 – 75 years with a Breast Cancer screening by SVI
Source: Epic SVI overall
(zip code)
Table 8.2.2: Percent of patients 40 – 75 years with a Breast Cancer screening by race Source: Epic
Table 8.2.3: Percent of patients 40 – 75 years with a Breast Cancer screening by ethnicity Source:
Table 8.2.4: Percent of patients 40 – 75 years with a Breast Cancer screening by language Source: Epic
Primary Care Physician (PCP)
Having a PCP was defined as having a health care provided documented in the electronic health record during 2023.
Table 8.3.1: Percent of patients 18 years and older with a PCP by SVI Source: Epic
Table 8.3.2: Percent of patients 18 years and older with a PCP by race Source: Epic
Table 8.3.3: Percent of patients 18 years and older with a PCP by ethnicity Source: Epic
Table 8.3.4: Percent of patients 18 years and older with a PCP by preferred language Source: Epic
Flu vaccine
Influenza vaccination is defined as all patients who received an influenza vaccination from January 1 to December 31, 2023. Influenza vaccination was defined through self-reported vaccination outside of Catholic Health and documentation of influenza vaccination administered in the electronic health record. Patients who were contraindicated for the flu vaccine were excluded. Contraindication was defined as hypersensitivity to eggs/thimerosal, had a prior negative reaction to a vaccination, had a bone marrow transplant within the last six months and had a history of Guillain-Barre syndrome. Patients who refused to receive a flu vaccination and did not receive a vaccination at another encounter were excluded.
Table 8.4.1: Percent of patients
60 years and older with an influenza vaccination by SVI
Source: Epic
Table 8.4.2: Percent of patients 60 years and older with an influenza vaccination by race Source: Epic
Table 8.4.3: Percent of patients 60 years and older with an influenza vaccination by ethnicity Source: Epic
Table 8.4.4: Percent of patients 60 years and older with an influenza vaccination by preferred language Source: Epic
St.
Annual Wellness Visit (AWV) or physical examination
Annual Wellness Visit or physical examination was measured by ICD codes related to an AWV or physical examination documented as visit diagnosis, billing diagnosis or on the patient’s problem list during 2023. If a patient had an ICD code documented during 2023, they were marked as “yes” having an AWV or physical exam during the 2023 year.
Table 8.5.1:
Percent of patients 18 years and older with an annual wellness visit or physical exam by SVI
Source: Epic
Table 8.5.2: Percent of patients 18 years and older with an
wellness visit or physical exam by race Source: Epic
physical exam with AWV/ physical exam
Table 8.5.3: Percent of patients 18 years and older with an annual wellness visit or physical exam by ethnicity Source: Epic
Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
Table 8.5.4: Percent of patients 18 years and older with an annual wellness visit or physical exam by preferred language Source: Epic
Language English Spanish Other languages
Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
# patients
patients with AWV/ physical exam # patients with AWV/ physical exam
# patients
patients with AWV/ physical exam # patients with AWV/ physical exam
Market-specific priority population Equity Action Plan for St. Catherine of Siena Hospital
Below, please find the health disparities the hospital will focus on improving, including the discreet action steps that will be tracked to close the identified gap.
Health disparity:
% patients with NO PCP
Identified intervention
• Education
• Patient access documentation
• Epic BPA build for provider notification
• Patient referral
Owner
• L. Yuditsky
Key stakeholders
• President
• CMO
• CNO
• COO
• ED Director
• Hospitalist Director
• Direct patient access
• TOC physician
• Care management
Key milestones
• Education provided
Timeline to completion
• End of year 2025
Resources
• Pt access representative
• Catholic Health Physician Partners
Measures of success
• 10% reduction in disparity between high and low vulnerable population
• Incremental increase in percentage of patients with a PCP
Health disparity:
% patients 40 – 75 years with a breast cancer screening
Identified intervention
• Visit local Hispanic community centers to offer Breast Cancer screening education and to assist with making appointments
Owner
• L. Yuditsky
Key stakeholders
• President
• CMO
• CNO
• COO
• Director Radiology
• PR & Community Relations
Key milestones
• Develop multi-language educational materials
• Identify community needs and groups to provide support to
• Begin hosting informational services
• Make patient appointments
Timeline to completion
• End of year 2025
Resources
• Personnel
• Educational materials in various languages
• Appointment availability
Measures of success
• Number of outreach events
• Appointments made
• 10% reduction in disparity between high and low vulnerable populations
Health disparity:
% patients with flu vaccine (60 & older)
Identified intervention
• Education
• Hx of influenza vaccine documented in immunization history section of Epic
• Provide additional flu pods to vulnerable populations within catchment area
Owner
• L. Yuditsky
Key stakeholders
• President
• CMO
• CNO
• COO
• Nursing Leadership
• PR & Community Relations
Key milestones
• Increase in outreach events during Fall/Winter 2024–2025
Timeline to completion
• End of year 2025
Resources
• Education
• Epic screen in ASAP
• Influenza vaccinations
Measures of success
• 10% increase in number of patients documented influenza vaccination
• Additional flu pods
St. Catherine of Siena Hospital
St. Charles Hospital Health Equity Strategic Plan
A note from the President
Dear Colleagues,
Part of our mission at Catholic Health is to have a comprehensive plan to enhance Health Equity across Long Island, serving those who are underserved and uninsured. At St. Charles Hospital, we are committed to fulfilling this mission by identifying social determinants of health (SDOH) in the communities we serve and subsequently, implement an all-encompassing community outreach program to address economic and social obstacles.
As part of Catholic Health’s deanery outreach program, St. Charles Hospital works closely with our local parishes in organizing “Healthy Sundays” in underserved communities. Healthy Sundays, staffed by our nurses, offers health education on a wide variety of topics and also offers free health screenings including blood pressure, cholesterol and glucose, as well as free flu vaccinations. The program aims to improve the quality of life in underserved and uninsured populations and reduce the risk of health issues, including obesity, diabetes and hypertension.
To address food insecurity, St. Charles Hospital launched a “Meals of Hope” food packing event as part of a Lenten project, where employees package soup ingredients (each package feeds six people). The soup packages are then distributed to our local parishes and shelters. This program helps to provide healthy, nutritious meals for thousands of Suffolk County residents in underserved communities.
In addition, Catholic Health and St. Charles Hospital, partnered with Long Island Cares, to provide food “to-go” bags for individuals who come to the hospital’s emergency department and are identified through screening as food insecure. If identified as such, individuals will receive a bag of food when they leave the hospital.
St. Charles Hospital also offers free, evidenced-based health improvement programs throughout the year. We collaborate with community-based organizations, such as the Suffolk County Department of Health and RSVP—Retired Senior Volunteer Program of Suffolk. Topics include Smoking Cessation, Diabetes Prevention, Falls Prevention and Living Healthy Workshops series.
All patients who come to St. Charles Hospital for medical care are offered services regardless of their ability to pay.
To better serve the uninsured and Medicaid patients, St. Charles Hospital recently opened its Maternity Clinic, which offers obstetrical routine prenatal care and delivery, obstetrical ultrasound, breastfeeding and lactation classes, post-partum education counseling and more. Over the past year, St. Charles has partnered with local pregnancy centers who counsel young women from underserved communities, and who need access to quality maternity care.
For all of the health equity initiatives I have outlined above, it is because of all of you that we are successful in fulfilling our mission to make sure that everyone in our communities has the same access to high-quality medical care, as well as health education regarding preventable diseases and free health screenings. Together we can make a difference in the lives of so many.
Sincerely,
James O’Connor President, St. Charles Hospital
St. Charles Hospital patient population overview
The following data were obtained from Epic and includes all patients who had an encounter with St. Charles Hospital from January 1 to December 31, 2023. Patents are only included in the sample once, even if they had more than one encounter with Catholic Health. Patients who died during or prior to 2023 were excluded from the sample.
Patient race
Figure 9.1: Patient race for all patients 18 years and older who had an encounter in 2023 (N=38,598).
Source: Epic
Ethnicity
Figure 9.2: Patient ethnicity for all patients 18 years and older who had an encounter in 2023 (N=38,598).
Source: Epic
Preferred language
Figure 9.3: Preferred language for all patients 18 years and older who had an encounter in 2023 (N=38,598).
Source: Epic
Social Vulnerability Index by Census Tract for St. Charles Hospital service areas
Figure 10.0: SVI by Census Tract for St. Charles Hospital service areas.
Source: Epic
St. Charles Hospital identified health disparities
All disparities have been measured using Chi-square tests for statistical significance. All analyses were statistically significant. All data were obtained through Epic and include all patients with any encounter at St. Charles Hospital from January 1 to December 31, 2023. Patients who died during or prior to 2023 were excluded from the sample. Age was calculated based upon each patients’ date of birth.
Race and ethnicity follow the Office of Management and Budget (OMB) federal race and ethnicity standard classifications. These are standard definitions provided by OMB to promote uniformity
Body Mass Index (BMI)
Table 9.1.1: Percent of patients 18 years and older with a BMI ≥25 by 2020 SVI
Source: Epic
and comparability for race and ethnicity data. These categories are used in the decennial census, household surveys, administrative forms and medical/public health research.
Preferred language was categorized as English, Spanish or other languages from the patient’s last stored value during 2023. Language data was disaggregated by our top two languages to facilitate visualization and statistical analyses. Stratification by preferred language does not include changes in self-reported preferred language.
Table 9.1.2: Percent of patients 18 years and older with a BMI ≥25 by race
Source: Epic
Table 9.1.3: Percent of patients 18 years and older with a BMI ≥25 by ethnicity
Source: Epic
Table 9.1.4: Percent of patients 18 years and older with a BMI ≥25 by preferred language Source: Epic
Breast Cancer screening
Breast cancer screening was defined as a patient having a breast cancer screening or mammography marked as completed from January 1, 2022 to December 31, 2023 for all women for all encounters in 2023.
Table 9.2.1:
Percent of patients
40 – 75 years with a Breast Cancer screening by SVI
Source: Epic
(zip code)
Table 9.2.2: Percent of patients 40 – 75 years with a Breast Cancer screening by race Source: Epic
Table 9.2.3: Percent of patients 40 – 75 years with a Breast Cancer screening by ethnicity Source:
Table 9.2.4: Percent of patients 40 – 75 years with a Breast Cancer screening by preferred language Source: Epic Language English
Primary Care Physician (PCP)
Having a PCP was defined as having a health care provided documented in the electronic health record during 2023.
Table 9.3.1: Percent of patients 18 years and older with a PCP by SVI
Source: Epic
Table 9.3.2: Percent of patients 18 years and older with a PCP by race Source: Epic
Table 9.3.3: Percent of patients 18 years and older with a PCP by ethnicity Source: Epic
Table 9.3.4: Percent of patients 18 years and older with a PCP by preferred language Source: Epic
Flu vaccine
Influenza vaccination is defined as all patients who received an influenza vaccination from January 1 to December 31, 2023. Influenza vaccination was defined through self-reported vaccination outside of Catholic Health and documentation of influenza vaccination administered in the electronic health record. Patients who were contraindicated for the flu vaccine were excluded. Contraindication was defined as hypersensitivity to eggs/thimerosal, had a prior negative reaction to a vaccination, had a bone marrow transplant within the last six months and had a history of Guillain-Barre syndrome. Patients who refused to receive a flu vaccination and did not receive a vaccination at another encounter were excluded.
Table 9.4.1:
Percent of patients
60 years and older with an influenza vaccination by SVI
Source: Epic
Table 9.4.2: Percent of patients 60 years and older with an influenza vaccination by race Source: Epic
Table 9.4.3: Percent of patients 60 years and older with an influenza vaccination by ethnicity Source: Epic
OMB Ethnicity Not Hispanic/Latino
Table 9.4.4: Percent of patients 60 years and older with an influenza vaccination by preferred language Source: Epic
Language English Spanish Other languages
Annual Wellness Visit (AWV) or physical examination
Annual Wellness Visit or physical examination was measured by ICD codes related to an AWV or physical examination documented as visit diagnosis, billing diagnosis or on the patient’s problem list during 2023. If a patient had an ICD code documented during 2023, they were marked as “yes” having an AWV or physical exam during the 2023 year.
Table 9.5.1:
Percent of patients 18 years and older with an annual wellness visit or physical exam by SVI
Source: Epic
Table 9.5.2: Percent of patients 18 years and older with an
wellness visit or physical exam by race Source: Epic
exam with AWV/ physical exam
Table 9.5.3: Percent of patients 18 years and older with an annual wellness visit or physical exam by ethnicity Source: Epic OMB Ethnicity Not Hispanic/Latino Hispanic/Latino No answer/unknown
Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
Table 9.5.4: Percent of patients 18 years and older with an annual wellness visit or physical exam by preferred language Source: Epic
Language English Spanish Other languages
Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
# patients
patients with AWV/ physical exam # patients with AWV/ physical exam
with AWV/ physical exam
with AWV/ physical exam
Market-specific priority population equity action plan for St. Charles Hospital
Below, please find the health disparities the hospital will focus on improving, including the discreet action steps that will be tracked to close the identified gap.
Health disparity: Primary care physician
Identified intervention
• Staff education
• Patient access documentation
• Epic BPA build for provider notification
• Patient referral and appointment with available PCP
• Special accommodation for 5N, 5S, 2N, and dental patients
• Monitoring report build
Owner
• C. Egbuziem
Key stakeholders
• President
• CMO
• CNO
• COO
• ED Director
• Hospitalist Director
• Director Patient Access
• Director Care Management
Key milestones
• Immediate implementation of documented interventions
• Beginning 11/2024, monthly reporting percent of patients presenting with no PCP who were successfully referred with appointments made
Health disparity: Annual physical
Identified intervention
• Staff Education
• Patient referral and appointment with available PCP
• Proposed Epic Report Build for AVS Annual Physical Appointment and Reminder
• Special accommodation for 5N, 5S, 2N, and Dental patients
Owner
Health disparity: Flu vaccine
Identified intervention
• Staff Education
• Implementation of influenza vaccination in Specialty Clinics
• Hx of seasonal influenza vaccine documented in the immunization history section of Epic
• Epic report build
• C. Egbuziem Owner
Key stakeholders
• President
• CMO
• CNO
• COO
• ED Director
• Nursing Leadership
• Hospitalist Director
• TOC Physician
Key milestones
• Immediate implementation of documented interventions
• Beginning 11/2024, monthly reporting percent of patients presenting with no PCP who were successfully referred with appointments made
• C. Egbuziem
Key stakeholders
• President
• CMO
• CNO
• COO
• Nursing Leadership
• Director of Pharmacy
• ED Med Rec Pharmacists
Key milestones
• Expansion of St. Charles Vaccine program to include the Specialty Clinics.
• Improving patient education in our chemical dependency units to improve the vaccination rate
• Ongoing community outreach programs with influenza vaccination offered
Timeline to completion
• January 2026
Resources
• Ongoing staff education
• Epic report Physicians for referral
Measures of success
• Percent of patients presenting with no PCP who were successfully referred with an appointment made
• 5% reduction in the number of patients documented with no PCP identified
Timeline to completion
• January 2026
Resources
• Ongoing Staff Education
• Epic report Physicians for referral
Measures of success
• Percent of patients presenting with no PCP who were successfully referred with an appointment made
• 5% increase in the number of patients documented with an Annual Physical Exam
Timeline to completion
• May 2025
Resources
• Ongoing Staff Education
• Influenza vaccines for Outpatient Specialty Clinics and community events
Measures of success
• Percent of patients in Outpatient Specialty Clinics, 5N, 5S, & 2N who were vaccinated for the 2024/2025 flu season
• 5% increase in the number of patients in highly vulnerable populations with documented influenza vaccination
St. Francis Hospital & Heart Center Health Equity Strategic Plan
A note from the President
Dear Colleagues,
At St. Francis Hospital & Heart Center we are guided by our mission, vision and values to achieve excellence in all that we do. The Health Equity Plan is developed with the goal of improving the health and well-being of all. We believe health care is a right, not a privilege.
Unfortunately, some Long Islanders face barriers to good health and as a result are more likely to suffer from preventable disease. Disparities in health outcomes are closely linked to social, economic and environmental factors.
Our Health Equity Plan aims to reduce health disparities by providing access to quality care to under-resourced communities and by addressing the social drivers of health. It is intended to identify actual or potential health care disparities among population groups, and in the way demographic groups access, experience and receive health care. The plan considers both individual and community needs.
Some of our Health Equity initiatives include the Student Athlete Program, providing cardiac screening for high school students free of charge; the Gift of Life Program, providing corrective cardiac procedures for children who cannot access this care in their own countries; a Community Outreach Program, providing a multitude of educational classes, screenings and vaccinations; and the Food is Medicine Program, providing a ready bag of food and referrals to nutrition resources for patients who are in need.
Together, we are making great strides towards improving health outcomes for all. Thank you for your ongoing care for our patients and our communities. I am proud of the work we’re doing and look forward to continuing to improve access to the exceptional health care at St. Francis.
Peace and all good,
Charles Lucore, MD, MBA President, St. Francis Hospital & Heart Center
St. Francis Hospital & Heart Center patient population overview
The following data were obtained from Epic and includes all patients who had an encounter with St. Francis Hospital & Heart Center from January 1 to December 31, 2023. Patents are only included in the sample once, even if they had more than one encounter with Catholic Health. Patients who died during or prior to 2023 were excluded from the sample.
Patient race
Figure 11.1: Patient race for all patients 18 years and older who had an encounter in 2023 (N=94,208).
Source: Epic
Ethnicity
Figure 11.2: Patient ethnicity for all patients 18 years and older who had an encounter in 2023 (N=94,208).
Source: Epic
Preferred language
Figure 11.3: Preferred language for all patients 18 years and older who had an encounter in 2023 (N=94,208)
Source: Epic
Social Vulnerability Index by Census Tract for St. Francis Hospital & Heart Center service areas
Figure 12.0: SVI by Census Tract for St. Francis Hospital & Heart Center service areas.
Source: Epic
St. Francis Hospital & Heart Center identified health disparities
All disparities have been measured using Chi-square tests for statistical significance. All analyses were statistically significant. All data were obtained through Epic and include all patients with any encounter at St. Francis Hospital & Heart Center from January 1 to December 31, 2023. Patients who died during or prior to 2023 were excluded from the sample. Age was calculated based upon each patients’ date of birth.
Race and ethnicity follow the Office of Management and Budget (OMB) federal race and ethnicity standard classifications. These are standard definitions provided by OMB to promote uniformity
Body Mass Index (BMI)
Table 10.1.1:
Percent of patients 18 years and older with a BMI ≥25 by 2020 SVI
Source: Epic
and comparability for race and ethnicity data. These categories are used in the decennial census, household surveys, administrative forms and medical/public health research.
Preferred language was categorized as English, Spanish or other languages from the patient’s last stored value during 2023. Language data was disaggregated by our top two languages to facilitate visualization and statistical analyses. Stratification by preferred language does not include changes in self-reported preferred language.
Table 10.1.2: Percent of patients 18 years and older with a BMI ≥25 by race Source: Epic
Table 10.1.3: Percent of patients 18 years and older with a BMI ≥25 by ethnicity Source: Epic
Table 10.1.4: Percent of patients 18 years and older with a BMI ≥25 by preferred language
Source: Epic
Breast Cancer screening
Breast cancer screening was defined as a patient having a breast cancer screening or mammography marked as completed from January 1, 2022 to December 31, 2023 for all women for all encounters in 2023.
Table 10.2.1: Percent of patients 40 – 75 years with a Breast Cancer screening by SVI
Source: Epic
Table 10.2.2: Percent of patients 40 – 75 years with a Breast Cancer screening by race Source: Epic
Table 10.2.3: Percent of patients 40 – 75 years with a Breast Cancer screening
Table 10.2.4: Percent of patients 40 – 75 years with a Breast Cancer screening by language Source: Epic Language
Primary Care Physician (PCP)
Having a PCP was defined as having a health care provided documented in the electronic health record during 2023.
Table 10.3.1: Percent of patients 18 years and older with a PCP by SVI Source: Epic
Table 10.3.2: Percent of patients 18 years and older with a PCP by race Source: Epic
Table 10.3.3: Percent of patients 18 years and older with a PCP by ethnicity Source: Epic
Table 10.3.4: Percent of patients 18 years and older with a PCP by preferred language Source: Epic
St. Francis Hospital & Heart Center
Flu vaccine
Influenza vaccination is defined as all patients who received an influenza vaccination from January 1 to December 31, 2023. Influenza vaccination was defined through self-reported vaccination outside of Catholic Health and documentation of influenza vaccination administered in the electronic health record. Patients who were contraindicated for the flu vaccine were excluded. Contraindication was defined as hypersensitivity to eggs/thimerosal, had a prior negative reaction to a vaccination, had a bone marrow transplant within the last six months and had a history of Guillain-Barre syndrome. Patients who refused to receive a flu vaccination and did not receive a vaccination at another encounter were excluded.
Table 10.4.1:
Percent of patients
60 years and older with an influenza vaccination by SVI
Source: Epic
Table 10.4.2: Percent of patients 60 years and older with an influenza vaccination by race Source: Epic
Table 10.4.3: Percent of patients 60 years and older with an influenza vaccination by ethnicity Source: Epic OMB Ethnicity Not
Table 10.4.4: Percent of patients 60 years and older with an influenza vaccination by preferred language Source: Epic
Language English
Annual Wellness Visit (AWV) or physical examination
Annual Wellness Visit or physical examination was measured by ICD codes related to an AWV or physical examination documented as visit diagnosis, billing diagnosis or on the patient’s problem list during 2023. If a patient had an ICD code documented during 2023, they were marked as “yes” having an AWV or physical exam during the 2023 year.
Table 10.5.1:
Percent of patients 18 years and older with an annual wellness visit or physical exam by SVI
Source: Epic
Table 10.5.2: Percent of patients 18 years and older with an
Source: Epic
with AWV/ physical exam with AWV/ physical exam
Table 10.5.3: Percent of patients 18 years and older with an annual wellness visit or physical exam by ethnicity Source: Epic OMB Ethnicity Not Hispanic/Latino Hispanic/Latino No answer/unknown
% patients with AWV/ physical exam # patients with AWV/ physical exam
with AWV/ physical exam
with AWV/ physical exam # patients with AWV/ physical exam
with AWV/ physical exam
Table 10.5.4: Percent of patients 18 years and older with an annual wellness visit or physical exam by preferred language Source: Epic
Language English Spanish Other languages Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
patients with AWV/ physical exam # patients with AWV/ physical exam
patients with AWV/ physical exam
patients with AWV/ physical exam
St. Francis Hospital & Heart Center
Market-specific priority population equity action plan for St. Francis Hospital & Heart Center
Below, please find the health disparities the hospital will focus on improving, including the discreet action steps that will be tracked to close the identified gap.
Health disparity: Influenza vaccination
Identified Intervention
• Increase influenza vaccination pods in communities with high SVI
Owner
• Quality & Performance Improvement
Key stakeholders
• Executive Leadership
• Community Health & Outreach Program
• Community Partners
• Pharmacy Department
Key milestones
• Identify communities with high SVI
• Strategize with Community Partners to establish influenza vaccination calendar of events
• Patients will receive electronic reminders of vaccination status
Timeline to completion
• 2024 – 2025 Flu Season
Resources
• Epic reporting
• Marketing
• Pharmacy
• Education
• Outreach Bus
Measures of success
• Additional influenza vaccination pods scheduled in communities identified with high SVI
Health disparity: Primary Care Provider (PCP)
Identified Intervention
• Identify a PCP for all patients
Owner
• Quality & Performance Improvement
Key stakeholders
• Executive Leadership
• Patient Access
• Care Management/Social Work
• Nursing
• Transitions of Care Program
• Catholic Health Physician Partners
• Community Outreach Program
Key milestones
• Staff education on PCP referral process and electronic health record documentation Community Health & Outreach events
• Patients will receive electronic reminders of upcoming appointments
Timeline to completion
• December 2025
Resources
• Epic reporting
• Compass Rose
• Find a Doctor Referral
• Catholic Health Physician Partners
• Catholic Health Central Referral
Measures of success
• Increase in number of patients assigned to a PCP
Health disparity: Annual Wellness Visit or Physical Exam
Identified Intervention
• Increase in number of patients with annual physical exam
Owner
• Quality & Performance Improvement
Key stakeholders
• Executive Leadership
• Patient Access
• Care Management/Social Work
• Nursing
• Transitions of Care Program
• Catholic Health Physician Partners
• Community Outreach Program
Key milestones
• Staff education on PCP referral process and electronic health record documentation Community Health & Outreach events
• Patients will receive electronic reminders of upcoming appointments
Timeline to completion
• December 2025
Resources
• Epic reporting Compass Rose
• Find a Doctor Referral
• Catholic Health Physician Partners
• Catholic Health Central Referral
Measures of success
• Increase in number of patients with documented annual physical exam
St. Joseph Hospital Health Equity Strategic Plan
A note from the President
Dear Colleagues,
Welcome to St. Joseph Hospital. As President of St. Joseph Hospital, it is my honor and pleasure to inform and assure you of our unwavering commitment to health equity through the implementation of our strategic plan. As we strive to provide exceptional care for all members of our community, we recognize that achieving health equity is not just our goal—it is our responsibility. This plan is not just a document; it is a roadmap for action.
We are deeply committed to promoting health equity within our community. We recognize that health disparities exist and that systemic barriers often prevent individuals from receiving the care they need. Our commitment is rooted in the belief that everyone deserves fair and just access to quality health care, regardless of their background. Some of the key initiatives of St. Joseph Hospital’s Health Equity Strategic Plan include:
• Actively engaging with diverse communities to help us better understand their needs and address health disparities.
• Promoting health equity by hosting community health fairs and providing free flu vaccines, blood pressure screenings and a variety of resources, ensuring that everyone has access to essential health care services.
• Providing education about health resources, preventive care and healthy lifestyles to empower our patients and community members.
• Enhancing access to primary care physicians (PCP) in order to promote health equity and improve overall health outcomes.
• Screening patients who come through our emergency department for food insecurity. Patients identified are provided with “to go” bags and our care management team provides additional referrals.
• Training our hospital staff in cultural competency to ensure that every patient feels respected and understood.
St. Joseph is fully committed to a future where every patient receives equitable care. Together, we can break down barriers and build a healthier community for all.
Sincerely,
Christopher J. Nelson President,
St. Joseph
Hospital
St. Joseph Hospital patient population overview
The following data were obtained from Epic and includes all patients who had an encounter with St. Joseph Hospital from January 1 to December 31, 2023. Patents are only included in the sample once, even if they had more than one encounter with Catholic Health. Patients who died during or prior to 2023 were excluded from the sample.
Patient race
Figure 13.1: Patient race for all patients 18 years and older who had and encounter in 2023 (N=29,004).
Source: Epic
Ethnicity
Figure 13.2: Patient ethnicity for all patients 18 years and older who had and encounter in 2023 (N=29,004). Source: Epic
Preferred language
Figure 13.3: Preferred language for all patients 18 years and older who had and encounter in 2023 (N=29,004).
Source: Epic
Social Vulnerability
Index by Census Tract for St. Joseph Hospital service areas
Figure 14.0: SVI by Census Tract for St. Francis Hospital & Heart Center service areas.
Source: Epic
St. Joseph Hospital identified health disparities
All disparities have been measured using Chi-square tests for statistical significance. All analyses were statistically significant. All data were obtained through Epic and include all patients with any encounter at St. Joseph Hospital from January 1 to December 31, 2023. Patients who died during or prior to 2023 were excluded from the sample. Age was calculated based upon each patients’ date of birth.
Race and ethnicity follow the Office of Management and Budget (OMB) federal race and ethnicity standard classifications. These are standard definitions provided by OMB to promote uniformity
Body Mass Index (BMI)
Table 10.1.1:
Percent of patients 18 years and older with a BMI ≥25 by 2020 SVI
Source: Epic
and comparability for race and ethnicity data. These categories are used in the decennial census, household surveys, administrative forms and medical/public health research.
Preferred language was categorized as English, Spanish or other languages from the patient’s last stored value during 2023. Language data was disaggregated by our top two languages to facilitate visualization and statistical analyses. Stratification by preferred language does not include changes in self-reported preferred language.
Table 10.1.2: Percent of patients 18 years and older with a BMI ≥25 by race
Source: Epic
Table 10.1.3: Percent of patients 18 years and older with a BMI ≥25 by ethnicity Source: Epic
Table 10.1.4: Percent of patients 18 years and older with a BMI ≥25 by preferred language
Source: Epic
Breast Cancer screening
Breast cancer screening was defined as a patient having a breast cancer screening or mammography marked as completed from January 1, 2022 to December 31, 2023 for all women for all encounters in 2023.
Table 10.2.1:
Percent of patients
40 – 75 years with a Breast Cancer screening by SVI
Source: Epic
overall percentile (zip code)
Table 10.2.2: Percent of patients 40 – 75 years with a Breast Cancer screening by race Source: Epic
Table 10.2.3: Percent of patients 40 – 75 years
Table 10.2.4: Percent of patients 40 – 75 years with a Breast Cancer screening by language Source: Epic
Primary Care Physician (PCP)
Having a PCP was defined as having a health care provided documented in the electronic health record during 2023.
Table 10.3.1: Percent of patients 18 years and older with a PCP by SVI
Source: Epic
Table 10.3.2: Percent of patients 18 years and older with a PCP by race Source: Epic
Table 10.3.3: Percent of patients 18 years and older with a PCP by ethnicity Source: Epic
Table 10.3.4: Percent of patients 18 years and older with a PCP by preferred language Source: Epic
Flu vaccine
Influenza vaccination is defined as all patients who received an influenza vaccination from January 1 to December 31, 2023. Influenza vaccination was defined through self-reported vaccination outside of Catholic Health and documentation of influenza vaccination administered in the electronic health record. Patients who were contraindicated for the flu vaccine were excluded. Contraindication was defined as hypersensitivity to eggs/thimerosal, had a prior negative reaction to a vaccination, had a bone marrow transplant within the last six months and had a history of Guillain-Barre syndrome. Patients who refused to receive a flu vaccination and did not receive a vaccination at another encounter were excluded.
Table 10.4.1:
Percent of patients
60 years and older with an influenza vaccination by SVI
Source: Epic
Table 10.4.2: Percent of patients 60 years and older with an influenza vaccination by race Source: Epic
Table 10.4.3: Percent of patients 60 years and older with an influenza vaccination by ethnicity Source: Epic
OMB Ethnicity Not Hispanic/Latino
Table 10.4.4: Percent of patients 60 years and older with an influenza vaccination by preferred language Source: Epic
Language English Spanish Other languages
Annual Wellness Visit (AWV) or physical examination
Annual Wellness Visit or physical examination was measured by ICD codes related to an AWV or physical examination documented as visit diagnosis, billing diagnosis or on the patient’s problem list during 2023. If a patient had an ICD code documented during 2023, they were marked as “yes” having an AWV or physical exam during the 2023 year.
Table 10.5.1:
Percent of patients 18 years and older with an annual wellness visit or physical exam by SVI Source: Epic
Table 10.5.2: Percent of patients 18 years and older with an
wellness visit or physical exam by race Source: Epic
exam with AWV/ physical exam
Table 10.5.3: Percent of patients 18 years and older with an annual wellness visit or physical exam by ethnicity Source: Epic
OMB Ethnicity Not Hispanic/Latino Hispanic/Latino No answer/unknown Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
with AWV/ physical exam
Table 10.5.4: Percent of patients 18 years and older with an annual wellness visit or physical exam by preferred language Source: Epic
Language English Spanish
Other languages Measures % patients with AWV/ physical exam # patients with AWV/ physical exam
patients
patients with AWV/ physical exam # patients with AWV/ physical exam
Market-specific priority population equity action plan for St. Joseph Hospital
Below, please find the health disparities the hospital will focus on improving, including the discreet action steps that will be tracked to close the identified gap.
Health disparity:
Percent of patients 60 years and older with an influenza vaccination
Identified intervention
• Schedule Flu vaccination pods in several local communities with elevated SVI
Owner
• Vice President of Quality and Performance Improvement
Key stakeholders
• Director of Pharmacy
• Manager of Public and Community Relations
• CNO
Key milestones
• Identify Local communities with elevated SVI
• Communicate with Community Relations/Community Partners to establish dates and locations for flu vaccination pods
• Schedule four additional flu pods in communities with elevated SVI as compared to 2023
Timeline to completion
• Complete by the end of the 2024 – 2025 Flu season
Resources
• Pharmacist
• Registered Nurses
• Vaccines
Measures of success
• St. Joseph Hospital will schedule four additional flu pods in communities with elevated SVI as compared to 2023
Health disparity:
Percent of Patients with a PCP (Primary Care Physician)
Identified intervention
• Identify patients without a PCP listed and refer patients to a local community PCP
Owner
• Vice President of Quality and Performance Improvement
Key stakeholders
• Health care Navigator
• Care Management/Social Work
• ED Physicians
• Nursing Staff
• CNO
• CMO
• Patient Access
Key milestones
• Create a report to capture patients without a PCP
• Establish relationships with various community physician offices
• Begin referring patients to community PCPs and scheduling appointments
• Create a process to enter PCP information into Epic to capture PCP data appropriately
Timeline to completion
• December 2025
Resources
• Health care Navigator
• Care Managers/Social Workers
Measures of success
• The percentage of Patients with a PCP in areas with high SVI will be monitored. The goal is to increase this percentage by 10% when compared to 2023
Acknowledgments
A special thanks to co-authors
• Lawrence Eisenstein, MD, MPH, FACP VP, Community and Public Health
• Gabriella Pandolfelli, PhD-c, MPH Director, Epidemiology and Public Health Analytics
Thank you to key contributors
• John Abalajon, RN, MS Clinical Analyst, Population Health
• John De Jesus Director, Strategic Planning & Implementation
• Kelly Derby, MHA AVP, Projects and Transformation
• Monique Ford, MBA, CPXP AVP, Quality Department
• Christine Hendriks, MA, MFA VP, Community Outreach
• Donna Mari Director, Brand & Advertising
• Randi Mednick, MHA VP, Strategic Planning
• Lisa Santeramo VP, Government Relations and Regulatory Affairs
• Annmarie Smith, EdD Director, Organizational Learning and Innovation
• Paul Stuart, MBA VP, Human Resources
• Jason Tagliarino, RN, MBA AVP, Population Health Systems
Campus Equity Leads
• Justin Jaycon, Director, Public and Community Relations, Good Samaritan University Hospital
• Christina Woods, Manager, Public and Community Relation, Good Samaritan University Hospital
• Nirvani Goolsarran, MD, FACP, CMQ, CHCQM Chair, Department of Internal Medicine, Chief Quality Officer, Mercy Hospital
• Laurie Yuditsky, RN, MBA, BSN, CPHQ VP, Quality and Patient Safety, St. Catherine of Siena Hospital
• Christopher Cells, FACHE VP, Ambulatory and Business Development, Mercy Hospital
• Chukwuma Egbuziem, MS, RN, CPHQ VP, Quality Management, St. Charles Hospital
• Stephen Trentowsk, SHRM-CP VP, Human Resources, St. Charles Hospital
• Ingrid Collymore, MSN, RN, CCM Manager, Quality & Performance Improvement, St. Francis Hospital & Heart Center
• Laurie Nolan-Kelley, DNP, RN VP, Quality and Performance Improvement, St. Francis Hospital & Heart Center
• Melanie Ambrose, MSN, RN VP, Quality and Performance Improvement, St. Joseph Hospital
• Bari Rees, MSW, MBA, LCSW Assistant Director, Care Coordination, St. Joseph Hospital
Health Equity Leadership Council Committee Chairs
• Catholic Health First: Paul Stuart, MBA VP, Human Resources
• Long Live Long Island: Lisa Santeramo VP, Government Relations and Regulatory Affairs
• Education: Annmarie Smith, EdD Director, Organizational Learning and Innovation
• Quality and Data: Monique Ford, MBA, CPXP AVP, Quality Department and Jason Tagliarino, RN, MBA AVP, Population Health Systems
Catholic Health Quality and Regulatory team leaders
• Monique Ford, MBA, CPXP AVP, Quality Department
• Chhavi Katyal, MD, MBA, MS SVP, System Chief Quality Officer
• Anna ten Napel, PhD, RN, NP SVP, System Chief Quality Officer
• Corinne Tramontana VP, Quality Programs and Clinical Data Analysis
Addendum
Long Live Long Island Subcommittee
Listening session summary report
By Lisa Santeramo and Scott Janke
Executive Summary
Catholic Health has established a multidisciplinary, system-wide Health Equity Leadership Council to further the mission of Catholic Health and its affiliated entities. The Council shall champion and steward the system’s continued advancements in health equity for its patients, its employees and the Long Island community, in a manner consistent with the system’s responsibilities under state and federal law and the Ethical and Religious Directives for Catholic Health Care Services as interpreted and applied by the Bishop of the Diocese of Rockville Centre.
The Long Live Long Island (LLLI) subcommittee is a part of the Health Equity Leadership Council. The scope of the LLLI subcommittee is to “address community partnerships, patient engagement and social drivers.”
The LLLI subcommittee has five objectives:
1. Establish a speakers bureau.
2. Plan and execute community listening sessions.
3. Curate equity-specific community events based on data and mission.
4. Collaborate with community-based organizations to address SDOH.
5. Seek community grants in alignment with key equity priorities. The purpose of this report is to outline our listening session findings.
Methodology
A working group within the subcommittee was created to achieve the objective of community listening sessions. The working group created a list of external community stakeholders working in the equity space, curated a standard list of questions and a response recording template. The initial list was comprised of over 365 leaders, but was later narrowed down to 134. The list was divided into those requiring one-to-one sessions with a member of the working group team and those that could be done in groups with Dr. Eisenstein. (Veterans, Housing, Youth, Spanish Speaking Religious Leaders).
From October 2023 to May 2024, the subcommittee reached out to all 134 organizations identified and interviewed over 50 community-based organizations spanning Long Island to identify gaps in social and health care service delivery. These organizations deliver a variety of social services to vulnerable populations, including affordable housing, vocational training, counseling, legal assistance, access to food, elderly supports and more. Engaging these organizations allowed the subcommittee to better understand the unique social challenges faced by different communities and gather valuable insights that will inform our strategies for enhancing health equity across Long Island as part of our population health initiatives. This collaborative will enable us to implement targeted improvements and ensure our health care system meets the diverse needs of all Long Islanders.
At least half of the organizations interviewed indicated that the lack of adequate transportation, food, affordable housing and financial insecurity posed as obstacles to accessing services. Many have tried to implement strategies to mitigate such obstacles, but noted more needs to be done. Additionally, many organizations noted their constituency consists of individuals with varying primary languages—with some organizations indicating this diversity could also pose as an obstacle to receiving services.
Notably, nearly all the organizations interviewed presented opportunities for various program partnerships with Catholic Health to address SDOH. The challenge is prioritizing those partnerships, evaluating potential return on investment and determining bandwidth within the health care system to execute these partnerships. This partnership evaluation should be done with the 1115 waiver process as the foundation for determining potential partnership opportunities.
Findings
Food insecurity
Nearly 80% of the organizations interviewed expressed concerns related to their clients’ abilities to secure food—many cited the rising cost of living as a primary driver. Other drivers include competing expenses (e.g., high rent prices) and public assistance not keeping pace with the cost of groceries. To combat food insecurity, the organizations organize food drives, partner with local food panties (e.g., Long Island Cares, Island Harvest) and other related organizations such as Meals on Wheels.
Transportation
Roughly half of the organizations interviewed indicated lack of transportation was a significant barrier to receiving services, with several organizations noting transportation as their greatest barrier (e.g., Great Neck Social Center, Mondays at Racine, Family & Children’s Association). Strategies utilized by the organizations to mitigate this challenge include using volunteers to transport clients, maintaining a transportation fund or grant-funded programs to provide transportation and utilizing non-emergent medical transportation services such as RideHealth, Thrive and Uber Health. Some organizations intentionally provide field-based services or deliver services in their clients’ homes. The Economic Opportunities Council of Suffolk noted the county’s bus system is challenging to use.
Housing and utilities
At least half of the organizations noted their clients are challenged by the rising cost of housing and utilities. Long Island is home to exceptionally high housing and rent prices and many client incomes surpass income requirements for housing assistance. For the elderly, the Family and Children’s Association noted tax growth on Long Island makes it difficult for seniors to stay in their homes. On the other hand, Minority Millennials noted the younger generation it serves is living with their families into adulthood due to their inability to keep up with the rising cost of housing and other competing utilities. For the homeless population, it can be difficult to find rental properties meeting “rent reasonableness” requirements and landlords willing to work with their clients. To assist clients in obtaining housing, some organizations noted their efforts to provide housing directly and work with the Community Development Corporation (CDC), Long Island Housing Partnership (LIHP) and Department of Social Services (DSS) for those who qualify for public support.
Language, diversity and cultural expectations
Over half of the organizations indicated their constituency consists of individuals with varying primary languages. Some organizations noted language barriers pose obstacles to receiving services and could lead to delayed care and lack of education or care coordination. There are difficulties in finding providers that speak non-English languages, especially specialty services. Many organizations noted their efforts to ensure their services are culturally competent—for example, ensuring staff providing services look and talk like their clients and share some of the same experiences. One organization (Chabad of Islip) noted there is major distrust between their constituency and the health care system and suggested there be more educational speakers and family practices representing their population.
Health care services
General concerns related to health insurance and prescription drug costs were expressed by the organizations. Their clients generally receive services from local clinics or trusted providers that have a strong reputation in their community. Economic Opportunities Council of Suffolk noted visiting specialists can be difficult due to lack of transportation and long wait lists for seeing Spanishspeaking providers, which leads to some clients visiting the local emergency room. Word-of-mouth can be critical for building trust between providers and certain communities.
The organizations noted several high-demand services utilized by their constituencies, including services treating diabetes, hypertension, high cholesterol, obesity, mental health, physical therapy, dental, eye care and hearing services.
Lack of education & trust
Numerous stakeholders that participated in the listening session identified a mistrust of authorities and experts as being a barrier to accessing health care. This as a cultural barrier that often accompanies communities with low income separate and distinct from language challenges. This barrier is most prevalent in the undocumented and migrant population however, it was also raised in the context of seniors due to the increase of scams targeting them for personal and financial information.
Challenges
The listening session process overall posed two obstacles:
1. Determining which groups could meet as a whole and speak openly about challenges verses groups that had to be interviewed one-to-one to have productive conversations
2. Lack of response and engagement by some of the identified groups. Despite numerous attempts, there were groups that didn’t respond to outreach or did not want to meet.
Despite these challenges, the working group was able to engage with a large group of stakeholders who work with groups that represent a diverse cross section of the Long Island population.
Conclusion
Catholic Health has enormous opportunity with Long Island’s community-based organizations to address SDOH. Interview results identified food insecurity as the foremost SDOH, closely followed by transportation. As a system, it is critical to prioritize specific issues and determine the bandwidth available to address such issues. This exercise should be done both within the context of the 1115 waiver but also as part of our ministry and mission work.
Organizations interviewed
• Adults and Children with Learning & Developmental Disabilities (ACLD)
• Association for Mental Health and Wellness
• Babylon Breast Cancer Coalition
• Bethel AME Church
• Brighter Tomorrows, Inc.
• Chabad of Islip
• Deanery Meeting for Good Samaritan University Hospital Catchment Area
– Fr. Gerry Gordon
– Rev. Joe Davanzo
– Msgr Brian McNamera
– Msgr. Joseph DeGrocco
– Rev. Dariusz Koszyk
– Msgr Richard Figliozzi
– Deacon Richard Becker
• Deepdale Cares
• EAC Network
• Empowerment Collaborative of Long Island—Victims Information Bureau of Suffolk County (ECLI VIBES)
• Economic Opportunities Council of Suffolk
• Family & Children’s Association
• Great Neck Social Center
• Health and Welfare Council of Long Island
• Housing Listening Session
– Neela Lockel, EAC
– Pilar Moya, Long Island Housing Services
– Lauren Hardin, Erase Racism
– Ian Wilder, Long Island Housing Services
– James Britz, LIHP
– Gwen O’Shea, CDC of Long Island
– Greta Guarton, Long Island Coalition for the Homeless
• Island Harvest
• Long Island Alzheimer’s and Dementia Center
• Long Island Cares
• LI NAACP, Tracey Edwards
• LI Youth for Christ
• Madonna Heights
• Minority Millennials
• Mondays at Racine
• The Mother’s Club of Wheatley Heights
• New Hour for Women and Children
• SILO
• Spanish-speaking religious leaders
– Bishop Romero
– Father Creagh
– 40+ pastors at our Lady of Loretto
• Strong Youth
• St. Vincent de Paul
• Suffolk County Office of the Aging
• Tomorrow’s Hope
• UCP of LI
• West Islip Breast Cancer Coalition
• Women’s Diversity Network
• Veterans Listening Session
– Leg Caracappa, Chair of the Suffolk Veterans Committee
– John McMurray
– Marcelle Leis, Suffolk County Veterans Service Agency
– Ray Meyer, Paws of War
– Justin Berbig, LI Cares Veterans Affairs
– Steve Castleton, Veteran Advocate and philanthropist (Army)
– Rich Dellasso, EOC of Suffolk
– Mark Murphy, Northport VA
– Brandi Carney, Northwell Military Division
– Adam Axina, MHAW
• United Way of Long Island
• Youth Listening Session
– Women’s Diversity Network
– Hope for Youth
– Town of Oyster Bay—North Massapequa Community Center
– Butterfly Effect
– Liga de Justica
– LI Headstart
Members of the working group
• Dr. Larry Eisenstein
• Lisa Santeramo
• Chris Cells
• Justin Jaycon
• Christina Woods
• Ingrid Collymore
• Christine Hendriks
• Alida Almonte-Giannini
• Ting Reiss
• Fannie Cheng
• Sue Palo
Appendix A
Goals of the listening sessions:
• LISTEN to what is NOT in the data.
• Identify challenges that the group faces.
• We may ultimately want to work with the group so they feel empowered and engaged, and we increase access to health care and services.
• Gather information on needs related to health care and social drivers.
• We DO NOT need to solve problems/make promises during these meetings.
• Thank the organization for their engagement and partnership.
Agenda for listening sessions:
• Brief overview of Catholic Health (4 to 5 sentences).
• Provide context on this meeting/goals of health equity at Catholic Health (i.e., working to increase health equity across Long Island, building a broad network and increasing engagement with community partners).
• What is health equity? (use image if helpful).
• Questions to ask:
1. Tell us about yourself and your organization? What services do you provide?
2. What are the greatest barriers for your constituents? What are the gaps for receiving services?
a. Do members have concerns with transportation?
b. Do members have concerns about securing food?
c. Do you have concerns about members being victims of domestic violence?
d. Do members have concerns about utilities or paying utility bills?
e. Do members have concerns about accessing affordable or safe housing?
3. What are the cultural expectations of your constituents when seeking care and when care is rendered to them?
4. What are the primary languages of the people you assist?
5. Where and how do you seek health care now?
6. Are you satisfied with your health care now and would you make any changes to the way you receive health care?
7. What do you think Catholic Health can do to assist you and your members to assist with overall health and well-being?
8. What other stakeholders would you recommend we engage with to further this work?
*After meeting, send follow-up email to community leader thanking them, summarizing findings and sending any initial follow-up questions that may not have been asked during meeting.
