Health Equity 2023-2024

Health Equity Strategic Plan

2023 – 2024

Lawrence Eisenstein, MD, MPH, FACP VP, Chief of Community and Public Health

A note from our president

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: 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 social determinants of health. 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 homecare 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. This report represents a written Health Equity Strategic Plan, which incorporates the pillars of the Community Health Roadmap. Demographic, financial, and other equity related 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.

The pillars of the Community Health Roadmap (see figure 1.0) are accompanied by objectives, and a general timeline. This Health Equity Strategic Plan solidifies certain deliverables and timeframes. One of the Community Health Roadmap deliverables

included the creation of a Health Equity Taskforce at Catholic Health. This has already been achieved, and the newly formed Health Equity Leadership Council (HELC) held its inaugural meeting on April 18, 2023. With representation from all campuses and major departments, the HELC has established an approved charter, and adopted a sub-committee structure in which four subcommittees have been assigned discreet action items based on the objectives of the Community Health Roadmap, specifically as they relate to health equity. New equity-related requirements from The Centers for Medicare and Medicaid (CMS), the Joint Commission, and even Leapfrog have heightened the awareness of the need for Catholic Health to incorporate equity-specific data collection, evaluation, and planning. This report summarizes the health equity efforts undertaken by Catholic Health and provides a strategic plan going forward.

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 2.1).

Social vulnerability index

The Social Vulnerability Index 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 social determinants of health (e.g., housing situation and transportation access).

REaL

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 (Race, Ethnicity, and Language data). 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.”

Equity as the central theme of the community 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 as follows.

Mission & Equity

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 sub-committee 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.

Figure 1.0

Other objectives and timelines within this pillar include:

Curate internal listening sessions (Target Q2, 2024)

• Create Equity Leadership Council (completed)

– Sub-committees named, Chairs assigned

– Committee Reports presented at system-wide Quality Committee meetings, and are shared with Catholic Health's Board of Directors

• Identify a system equity leader (completed)

– Train and engage campus equity champions (Q4, 2023 – Q4, 2024)

• Develop system-wide education (ongoing)

– Mandated trainings (ie: implicit bias training) (Q4, 2023)

– Explore GME curriculum (Q2, 2024)

• Ongoing Assessment, education, and re-education (ongoing)

• Create leadership and mentorship opportunities for minority team members (ongoing)

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)

• Community events based on data and mission (ongoing)

• Improve demographic data collection (Q4, 2023)

• Measure linkage to care (Q4, 2024)

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)

• Joint Mission/Equity initiative through parishes (ongoing)

– 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)

– 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 growth)

• Leadership and advancement opportunities (ongoing)

• Evaluate community events for results, use resources efficiently (ongoing)

Social determinants of health

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 Social Determinants of Health (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 (CBO) 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 CBO 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 Social Determinants of Health include:

• Create and implement system wide screening tool for SDoH to be added to patient care roadmap (Q4, 2023)

• Train staff on asking and collecting SDoH data (Q4, 2023)

• Collaboration with Community Based Organizations (vital partners) (ongoing)

• Use emerging technology/program to close the CBO communication loop (evaluation of existing products in progress)

• Align ACO, community clinical partners (i.e., FQHC) (ongoing)

• Food insecurity is a model program, grow “to-go bag” initiative (complete)

• 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:

• Develop equity quality metrics (create dashboard) (Q4, 2023)

• Equity report at QMC meetings (ongoing)

• Follow AHA roadmap milestones (ongoing)

• Train staff in cultural appropriateness, mandate trainings (2024)

• Evaluate patient experience ratings for improvements (ongoing)

• Utilize IT tools to assess Catholic Health and partner equity performance (Q1, 2024)

• Apply for “Healthcare Equity Certification” when qualified

Regulatory requirements

Catholic Health diligently monitors updates and 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.

Pending 1115 Medicaid waiver

Catholic Health has been preparing for the expected enactment of the 1115 Medicaid Waiver in New York State. Although specific details remain unknown at this time, Catholic Health has participated in meetings of likely vital collective partners including the HWCLI, Harmony and SunRiver Health (local federally qualified health centers) to prepare the working relationships and infrastructure for what is expected from the Waiver. A pilot process incorporating our community-based partners is beginning at our Mercy Hospital campus as we strive to be immediately prepared at the start of the Waiver.

Health Equity Leadership Council (HELC)

Catholic Health has established a multidisciplinary systemwide Health Equity Leadership Council (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.

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 the 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 social determinants of health to improve overall health outcomes and decrease unnecessary hospital admissions and readmissions.

• Meet emerging regulatory and industry requirements relative to health equity.

Subcommittees of the Council

Island

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.

Catholic Health First

Long

Demographics of Catholic Health’s patients

The following data is based on patient encounters from January 1, 2022 – December 31, 2022

Patient race

Figure 1.1 – Source: Epic

Black or African American

American Indian or Alaskan Asian

Ethnicity

Figure 1.2 – Source: Epic

Preferred language

Figure 1.3 – Source: Epic

2020 Social Vulnerability Index by Census Tract for Queens, Nassau and Suffolk

Figure 2.1 – Source: Epic

Identified system-wide health disparities

All disparities have been measured using Chi-square testing for statistical significance. All disparities are statistically significant except for the breast cancer screening rates at St. Joseph’s Hospital.

Body Mass Index, % of patients with BMI >25

Figure 3.1 – Source: Epic

Parameters: All individuals encountered at each hospital, 20 years and older.

Breast cancer screening, % of patients with breast cancer screening

Figure 3.2 – Source: Epic Parameters:

2022, 50 – 75 years old.

Primary care physician, % of patients with no PCP

Figure 3.3 – Source: Epic

Parameters: All individuals encountered in 2022.

Flu vaccine, % of patients with flu vaccine (60 and older)

Figure 3.4 – Source: Epic Parameters: All individuals encountered in 2022, 60 years and older.

Annual physical, % of patients who had annual physical exam

Figure 3.5 – Source: Epic Parameters: All individuals encountered in 2022, 18 – 85 years old.

Areas for improved documentation

The following parameters represent opportunities for improved health equity documentation. Based on other data sources, these numbers are likely underreported in Epic. Actual work being done across Catholic Health on these parameters is likely significantly more thorough than reflected below. Catholic Health commits to improving documentation and reporting on equity-related measures.

Diabetic foot exam, % of diabetic patients with foot exam

Figure 4.1 – Source: Epic

HbA1c screening, % of diabetic patients with HbA1c test

Figure 4.2– Source: Epic

in 2022.

on the

in 2022.

Depression screening, % of patients with depression

Figure 4.3– Source: Epic

Parameters: All individuals 18 and over encountered in 2022 with a documented diagnosis of depression.

St. Charles Hospital Health Equity Strategic Plan

Priority population

Patient population overview

Patient race

Figure 5.1 – Source: Epic

White or Caucasian

Black or African American Other

American Indian or Alaskan Asian

Pacific Islander

Patient refused

Unknown

Ethnicity

Figure 5.2 – Source: Epic

Not Hispanic or Latino

Patient refused Hispanic or Latino

Unknown

Social Vulnerability Index by Census

Tract

Figure 5.4 – Source: Epic

Preferred language

Figure 5.3 – Source: Epic

Unknown Greek Hindi Chinese Creole Italian Polish Korean Other Spanish English

Identified

health disparities

Body Mass Index, % of patients with BMI >25

Figure 5.5 – Source: Epic Parameters: All individuals encountered at each hospital, 20 years and older.

Breast cancer screening, % of patients with breast cancer screening

Figure 5.6 – Source: Epic Parameters: All females encountered in 2022, 50 – 75 years old.

Primary care physician, % of patients with no PCP

Figure 5.7 – Source: Epic Parameters: All individuals encountered in 2022.

Flu vaccine, % of patients with flu vaccine (60 and older)

Figure 5.8 – Source: Epic Parameters: All individuals encountered in 2022, 60 years and older.

Annual physical, % of patients with annual physical

Figure 5.9 – Source: Epic Parameters: All individuals encountered in 2022, 18 – 85 years old.

St. Charles Hospital

Market-specific priority population equity action plan

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

• Direct Patient Access

• Director Care Management

Key milestones

• 12/31/23 Education provided

• Q1 2.5% improvement

• Q2 5% improvement

• Q3 7.5% improvement

• 2024 10% improvement

Timeline to completion

• 12/31/23 Education completed

• 10% improvement by end of 2024

Resources

• Education

• Epic report physicians for referral

Measures of success

• 10% reduction in number of patients documented with no PCP identified

Health disparity: Annual physical

Identified Intervention

• Staff education

• Epic screening question build (flow sheet or discreet field in H&P template)

• Workflow to be determined for ED and inpatient

• Proposed Epic report build for AVS annual physical appointment and reminder

• Special accommodation for 5N, 5S, 2N and dental patients

Owner

• C. Egbuziem

Key stakeholders

• President

• CMO

• CNO

• COO

• ED Director

• Nursing Leadership

• Hospitalist Director

• TOC Physician

Key milestones

• 12/31/23 Education provided

• Q1 2.5% improvement

• Q2 5% improvement

• Q3 7.5% improvement

• 2024 10% improvement

Timeline to completion

• 12/31/23 Education completed

• 10% improvement by end of 2024

Resources

• Education

• Epic report physicians for referral

Measures of success

• 10% increase in number of patients documented with an annual physical exam

Health disparity: Flu vaccine

Identified Intervention

• Staff education

• Screen and immunize ED treat & release patients

• Flu screening added to ASAP Epic

• Influenza vaccination supply to ED

• History of seasonal influenza vaccine documented in immunization history section of Epic

• Epic report build

Owner

• C. Egbuziem

Key stakeholders

• President

• CMO

• CNO

• COO

• ED Director

• Nursing Leadership

• Director of Pharmacy

• ED Med Rec Pharmacists

Key milestones

• 12/31/23 Education provided

• Q1 2.5% improvement

• Q2 5% improvement

• Q3 7.5% improvement

• 2024 10% improvement

Timeline to completion

• 12/31/23 Education completed

• 10% improvement by end of 2024

Resources

• Education

• Flu screen in Epic ASAP for influenza vaccinations

Measures of success

• 10% increase in number of patients documented influenza vaccination

St. Francis Hospital & Heart Center ® Health Equity Strategic Plan

Priority population

Patient population overview

Patient race

Figure 6.1 – Source: Epic

Ethnicity

Figure 6.2 – Source: Epic

Preferred language

Figure 6.3 – Source: Epic

Social Vulnerability Index by Census Tract

Figure 6.4– Source: Epic

Identified

health disparities

Body Mass Index, % of patients with BMI >25

Figure 6.5 – Source: Epic Parameters: All individuals encountered at each hospital, 20 years and older.

Breast cancer screening, % of patients with breast cancer screening

Figure 6.6 – Source: Epic Parameters: All females encountered in 2022, 50 – 75 years old.

Primary care physician, % of patients with no PCP

Figure 6.7 – Source: Epic Parameters: All individuals encountered in 2022.

Flu vaccine, % of patients with flu vaccine (60 and older)

Figure 6.8 – Source: Epic Parameters: All individuals encountered in 2022, 60 years and older.

Annual physical, % of patients with annual physical exam

Figure 6.9– Source: Epic Parameters: All individuals encountered in 2022, 18 – 85 years old.

SVI

St.

St. Francis Hospital & Heart Center ®

Market-specific priority population equity action plan

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: Breast cancer screening

Identified Intervention

• Patients 55 – 75 years old seen in PAT and ED will be asked if they have had a breast cancer screening in the past 12 months

Owner

• PAT

• ED Triage

Key stakeholders

• QAPI

Key milestones

• Education of stakeholders by 12/23

• Measurable improvement from baseline by Q2/2024

Timeline to completion

• 1/1 – 12/2024

Resources

• Epic Reporting

• Education

Measures of success

• Improved documentation

• Increased referrals to The Women’s Health Center

Health disparity: Flu vaccine

Identified Intervention

• From September to May patients 60 years and older will be asked if they have had a flu season vaccine

Owner

• ED

• PAT

• Patient Access

Key stakeholders

• Nursing

Key milestones

• Education of stakeholders by 12/2023

• Measurable improvement from baseline by Q2/2024

Timeline to completion

• 1/1 – 12/2024

Resources

• Epic reporting

• Education

Measures of success

• Improved documentation

• Vaccine given or declined

Health disparity: Primary care physician

Identified Intervention

• Patients seen in PAT, ED, Patient Access will be asked if they have a primary care physician

Owner

• ED

• PAT

• Patient Access

Key stakeholders

• Care management

Key milestones

• Education of stakeholders by 12/2023

• Measurable improvement from baseline by Q2/2024

Timeline to completion

• 1/1 – 12/2024

Resources

• Epic Reporting

• Education

Measures of success

• Improved documentation

• Increased referrals to Catholic Health Physician Partners

St. Catherine of Siena Hospital Health Equity Strategic Plan

Priority population

Patient population overview

Patient race

Figure 7.1 – Source: Epic

White or Caucasian

Black or African American Other

American Indian or Alaskan Asian

Pacific Islander

Ethnicity

Figure 7.2 – Source: Epic

Preferred language

Figure 7.3 – Source: Epic

Social Vulnerability Index by Census Tract

Figure 7.4– Source: Epic

Identified

health disparities

Body Mass Index, % of patients with BMI >25

Figure 7.5– Source: Epic Parameters: All individuals encountered at each hospital, 20 years and older.

Breast cancer screening, % of patients with breast cancer screening

Figure 7.6– Source: Epic Parameters: All females encountered in 2022, 50 – 75 years old.

Primary care physician, % of patients with no PCP

Figure 7.7– Source: Epic Parameters: All individuals encountered in 2022.

Flu vaccine, % of patients with flu vaccine (60 and older)

Figure 7.8– Source: Epic Parameters: All individuals encountered in 2022, 60 years and older.

Annual physical, % of patients with annual physical

Figure 7.5– Source: Epic Parameters: All individuals encountered in 2022, 18 – 85 years old.

St. Catherine of Siena Hospital

St. Catherine of Siena Hospital

Market-specific priority population equity action plan

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: % of patients with no PCP

Identified Iintervention

• Education

• Patient access documentation

• Epic BPA build for provider notification

• Patient referral

• Monitoring report build

Owner

• L. Yuditsky

Key stakeholders

• President

• CMO

• CNO

• COO

• ED director

• Hospitalist director

• Direct patient access

• TOC physician

• Care management

Key milestones

• 12/31/23 Education provided

• Q1 2.5% improvement

• Q2 5% improvement

• Q3 7.5% improvement

• 2024 10% improvement

Timeline to completion

• 12/31/23 Education completed

• 10% improvement by end of 2024

Resources

• Education

• Epic report

• Physicians for referral

Measures of success

• 10% reduction in number of patients documented with no PCP identified

Health disparity: % of patients with annual physical exam

Identified intervention

• Epic screening question build (flow sheet or discreet field in H&P template

• Report build

• AVS physical reminder if patient answers no

Owner

• L. Yuditsky

Key stakeholders

• President

• CMO

• CNO

• COO

• ED director

• Nursing leadership

• Hospitalist director

• TOC physician

Key milestones

• 12/31/23 Education provided

• Q1 2.5% improvement

• Q2 5% improvement

• Q3 7.5% improvement

• 2024 10% improvement

Timeline to completion

• 12/31/23 Education completed

• 10% improvement by end of 2024

Resources

• Education

• Epic report

• Physicians for referral

Measures of success

• 10% increase in number of patients documented with an annual physical exam

Health disparity: % of patients with flu vaccine (60 and older)

Identified intervention

• Screen and immunize ED treat & release patients

• Education

• Flu screening added to ASAP Epic

• Influenza vaccination supply to ED

• History of seasonal influenza vaccine documented in immunization history section of Epic

• Epic report build

Owner

• L. Yuditsky

Key stakeholders

• President

• CMO

• CNO

• COO

• ED director

• Nursing leadership

• Director of pharmacy

• ED med rec pharmacists

Key milestones

• 12/31/23 Education provided

• Q1 2.5% improvement

• Q2 5% improvement

• Q3 7.5% improvement

• 2024 10% improvement

Timeline to completion

• 12/31/23 Edu completed

• 10% improvement by end of 2024

Resources

• Education

• Epic screen in ASAP

• Influenza vaccinations

Measures of success

• 10% increase in number of patients documented influenza vaccination

St. Joseph Hospital Health Equity Strategic Plan

Priority population

Patient population overview

Patient race

Figure 8.1 – Source: Epic

Black or African American Other White or Caucasian

American Indian or Alaskan Asian

Pacific Islander

Ethnicity

Figure 8.2 – Source: Epic

Preferred language Figure 8.3 – Source: Epic

Social Vulnerability Index by Census

Tract

Figure 8.4– Source: Epic

Identified

health disparities

Body Mass Index, % of patients with BMI >25

Figure 8.5– Source: Epic Parameters: All individuals encountered at each hospital, 20 years and older.

Breast cancer screening, % of patients with breast cancer screening

Figure 8.6– Source: Epic Parameters: All females encountered in 2022, 50-75 years old.

Primary care physician, % of patients with no PCP

Figure 8.7– Source: Epic Parameters: All individuals encountered in 2022.

Flu vaccine, % of patients with flu vaccine (60 and older)

Note: This measure showed there was not statistically significant correlation; however, this could be due to a small sample too small to uncover a relationship.

Figure 8.8 – Source: Epic Parameters: All individuals encountered in 2022, 60 years and older. SVI

Annual physical, % of patients with annual physical exam

Figure 8.9 – Source: Epic Parameters: All individuals encountered in 2022, 18 – 85 years old.

St. Joseph Hospital

Market-specific priority population equity action plan

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 and older

Identified intervention

• Schedule flu vaccination pods in several local communities with high SVI

Owner

• Melanie Ambrose

Key stakeholders

• Mark Macchia

• Liz Schwind

• CNO

Key milestones

• Identify local communities with high SVI

• Communicate with Community Relations/Community Partners to establish dates and locations for flu vaccination pods

• Schedule 4 additional flu pods in communities with high SVI as compared to 2023

Timeline to completion

• December 2024

Resources

• Pharmacist

• RN

Health disparity: % of patients with no PCP

Identified intervention

• Identify a PCP for all patients and refer patients without a PCP who are uninsured or underinsured to an established physician/clinic

Owner

• Melanie Ambrose

Key stakeholders

• ED physicians

• Nursing staff

• CNO

• CMO

• Patient access

Key milestones

• Educate staff to ensure PCPs are appropriately documented in the medical record

• Identify a physician/clinic to see uninsured or underinsured patients who do not have a PCP

• Educate staff to refer uninsured or underinsured patients to the established physician/clinic when appropriate

• Review data to ensure that staff is appropriately assigning PCP and referring patients to established physician/clinic when appropriate

Timeline to completion

• December 2025

Health disparity: % of patients with annual physical exam

Identified intervention

• Identify a PCP for all patients and refer patients without a PCP who are uninsured or underinsured to an established physician/clinic for a physical exam

Owner

• Melanie Ambrose

Key stakeholders

• ED physicians

• Nursing staff

• CNO

• CMO

• Patient access

Key milestones

• Educate staff to ensure PCPs are appropriately documented in the medical record

• Identify a physician/clinic to see uninsured or underinsured patients who do not have a PCP

• Educate staff to refer uninsured or underinsured patients to the established physician/clinic when appropriate

• Review data to ensure that staff is appropriately assigning PCP and referring patients to established physician/clinic when appropriate

Timeline to completion

• December 2025

• Vaccines Resources Resources

Measures of success

• 4 additional flu vaccination Pods scheduled in communities with a high SVI as compared to 2023

Measures of success

• 90% of patients have a PCP documented in the medical record

Measures of success

• 90% of patients have a PCP documented in the medical record

Good Samaritan University Hospital Health Equity Strategic Plan

Priority population

Patient population overview

Patient race

Figure 9.1 – Source: Epic

Ethnicity

Figure 9.2 – Source: Epic

Preferred language Figure 9.3 – Source: Epic

Social Vulnerability Index by Census Tract

Figure 9.4– Source: Epic

Identified health disparities

Body Mass Index, % of patients with BMI >25

Figure 9.5 – Source: Epic

Parameters: All individuals encountered at each hospital, 20 years and older.

Breast cancer screening, % of patients with breast cancer screening

Figure 9.6 – Source: Epic

Parameters: All females encountered in 2022, 50 – 75 years old.

Primary care physician, % of patients with no PCP

Figure 9.7 – Source: Epic

Parameters: All individuals encountered in 2022.

Flu vaccine, % of patients with flu vaccine (60 and older)

Figure 9.8 – Source: Epic

Parameters: All individuals encountered in 2022, 60 years and older.

Annual physical, % of patients with annual physical exam

Figure 9.9 – Source: Epic

Parameters: All individuals encountered in 2022, 18 – 85 years old.

SVI

Market-specific priority population equity action plan

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 and older

Identified intervention

• Increase in flu shot clinics in strategic locations

Health disparity:

% of patients with no PCP

Identified intervention

• Increase Referrals to PCP from the Emergency Medicine Population

Owner

• Public & community relations

Key stakeholders

• Underserved community members who are highly vulnerable in target communities—Brentwood, Bay Shore, 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 2025

Resources

• Administration, pharmacy (vaccine), public & community relations (promotions), volunteer clinicians, increased documentation of encounters into Epic

Measures of success

• Goal: 5% increase in flu shots in highly vulnerable populations

• Reach: 8% increase in highly vulnerable populations

Owner

• Patient access, care managers

Key stakeholders

• Underserved community members who are highly vulnerable in target communities—Brentwood, Bay Shore, Central Islip

Key milestones

• ED, inpatient, diabetes education center, PCP encounter

Timeline to completion

• January 2025

Resources

• Patient access, emergency department staff, CH Central Referral Office (CRO)

Measures of success

• Goal: 5% increase in patients w/ a PCP in highly vulnerable populations

• Reach: 8% increase in highly vulnerable populations

Health disparity: % of 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

• PCPs, OBGYNs, Enhanced Marketing, Parishes, CBOs, Elected Officials

Key stakeholders

• Underserved community members who are highly vulnerable in target communities—Brentwood, Bay Shore, Central Islip

Key milestones

• Women’s health events in May (Mothers Day) and October (Breast Health Awareness Month. Additional screening events in subsequent months

Timeline to completion

• January 2025

Resources

• Women’s Imaging Center

Measures of success

• Goal: % increase in patients w/ a PCP in highly vulnerable populations

• Reach: 8% increase in highly vulnerable populations

Mercy Hospital Health Equity Strategic Plan

Priority population

Patient population overview

Patient race

Figure 10.1 – Source: Epic

Ethnicity

Figure 10.2 – Source: Epic

Social Vulnerability Index by Census Tract

Figure 10.4– Source: Epic

Identified

health disparities

Body Mass Index, % of patients with BMI >25

Figure 10.5 – Source: Epic Parameters: All individuals encountered at each hospital, 20 years and older.

Breast cancer screening, % of patients with breast cancer screening

Figure 10.6 – Source: Epic Parameters: All females encountered in 2022, 50 – 75 years old.

Primary care physician, % of patients with no PCP

Figure 10.7 – Source: Epic Parameters: All individuals encountered in 2022.

Flu vaccine, % of patients with flu vaccine (60 and older)

Figure 10.8 – Source: Epic Parameters: All individuals encountered in 2022, 60 years and older.

Annual physical, % of patients with annual physical exam

Figure 10.9 – Source: Epic Parameters: All individuals encountered in 2022, 18 – 85 years old.

Market-specific priority population equity action plan

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: No primary care physician

Identified intervention

• PACED Program

Owner

• Brian Massari

Key stakeholders

• Brian Massari

• Dr. Bramante

Key milestones

• Completion of training for patient access

Timeline to completion

• Go live 11/1/2023

Resources

• Staffing & education

Measures of success

• Monitor number of NOPCP referrals to CRO

Identified intervention

• FM in Ryan/FCC

Owner

• Chris Cells

Key stakeholders

• Chris Cells

• Jeanine Cappello

• Dr. Canedo

• Dr. Charles

• Catholic Health Medical Group

Key milestones

• Opening of sites of care

Timeline to completion

• Family Care Center opened 10/2/2023; Ryan building opening 12/15/2023

Resources

• Construction & financing

Measures of success

• Successful opening of business units

Identified intervention

• Inpatient Pull to Ryan/FCC

Owner

• Chris Cells

Key stakeholders

• Dr. Goolsarran

• Chris Ruppert

• Chris Cell

• Debra Guerrini

Key milestones

• Workflow development and staff training

Timeline to completion

• 3 – 6 months

Resources

• Education

Measures of success

• Monitor number of NOPCP follow-ups from inpatient discharges to Family Care Center

Health disparity: Flu vaccination

Identified intervention

• See no PCP action plan

Identified intervention

• Improve inpatient influenza vaccination rates

Owner

• Dr. Goolsarran

Identified Intervention

• Electronic annual reminders to FCC patients

• Chris Ruppert Owner

Key Sstakeholders

• Dr. Goolsarran

• Chris Ruppert

• Annemarie Kesicier

Key milestones

• Achieve >80% vaccination rate using Epic auto order

• Use as quality core measure

Timeline to completion

• 6 months – 1 year

Resources

• Flu vax stocking on units

• Brian Massari

Key stakeholders

• Patient Access

• IT

Key milestones

• Feasibility analysis

Timeline to completion

• TBD, pending feasibility analysis

• Education on importance Resources

Measures of success

• Auto order compliance and % administration of vaccines

Health disparity: Annual physical

Identified Intervention

• See no PCP action plan

• TBD, pending feasibility analysis

Measures of success

• Implementation of technology

Identified intervention

• Electronic annual reminders to FCC patients

Owner

• Brian Massari

Key stakeholders

• Patient Access

• IT

Key milestones

• Feasibility analysis

Timeline to completion

• TBD, pending feasibility analysis

Resources

• TBD, pending feasibility analysis

Measures of success

• Implementation of technology

Identified intervention

• Reporting on individuals due for flu vaccinations and proactively outreach

Owner

• Brian Massari

• Jeanine Cappello

Key stakeholders

• Patient Access

• IT

Key milestones

• Development of Report, implementation of process

Timeline to completion

• 3 – 6 months

Resources

• Technology, staffing, education

Measures of success

• >85% of patients due for an influenza vaccination are reached proactively

Identified intervention

• Reporting on individuals due for annual physicals and proactively outreach

Owner

• Brian Massari

• Jeanine Cappello

Key stakeholders

• Patient Access

• IT

Key milestones

• Development of Report, implementation of process

Timeline to completion

• 3 – 6 months

Resources

• Technology

Measures of success

• >85% of patients due for an influenza vaccination are reached proactively

Acknowledgments

A special thanks to co-authors:

• Steven Budnick, Intern, Binghamton University

• Kelly Donnelly, AVP, Projects and Transformation

Thank you to key contributors

• John Abalajon, Clinical Analyst, Population Health

• Steven Budnick, Intern, Binghamton University

• Joseph Carofano, SVP, Strategy & Chief Marketing Officer

• Allyson Collins, VP, Digital Strategy

• Kelly Donnelly, AVP, Projects and Transformation

• Monique Ford, AVP, Quality

• Jason Golbin, DO, MBA, MS, EVP, Chief Medical Officer

• Christina Hartnett, Sr. Manager, Data Science

• Christine Hendriks, VP, Community Outreach

• Joseph Lamantia, EVP, Chief Transformation Officer

• Michael Mainiero, SVP, Chief Digital Information Officer

• Donna Mari, Director, Brand & Advertising

• Randi Mednick, VP, Strategic Planning

• Binjil Mupo, Epic

• Jason Tagliarino, AVP, Population Health Systems

Health Equity Leadership Council committee chairs

• Catholic Health First: Paul Stuart

• Long Live Long Island: Chris Cells, Lisa Santeramo

• Education: Annmarie Smith

• Quality and Data: Allyson Collins, Monique Ford

Catholic Health Quality and regulatory team leaders

• Chhavi Katyal, MD, MBA, MS, SVP, System Chief Quality Officer, Patient Experience Officer

• Monique Ford, AVP, Quality

• Corrinne Tramantona, VP, Quality and Clinical Data Analysis

• Anna ten Napel, PhD, RN, NP, VP, Regulatory Affairs and Performance Improvement

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Rockville Centre, NY 11570