Driving equity in health care: Lessons from COVID-19 – . Health Blog
Editor's Note: Part Three in a Series on the Impact of COVID-19 on Color Communities and Responses to Improve Health Equity. Click here to read part one and here to read part two.
If there's a silver lining from COVID-19, we need to address monumental health disparities, particularly racial and ethnic disparities. I've worked on healthcare disparities for more than two decades, but I've never seen our healthcare system move so quickly. In the U.S., those of us in health care have sought to fill the gaps and better understand why COVID-19 is disproportionately affecting color communities and immigrants – and, indeed, anyone dealing with social determinants of health like housing shortages and food insecurity struggles and has access to good education.
An important lesson: lived experience should guide change
I came to this country as an undocumented immigrant when I was 13 years old. English was not my first language. My mother was a single teenage mother and I have only seen my father twice in my life. My childhood was filled with all of the trauma we hear about from many of our patients: domestic violence, drug addiction, mental health problems, nursing and more. So, as you can imagine, all of this feels very personal to me and drives my work as director of the Disparities Solutions Center at Massachusetts General Hospital.
An important lesson is that there is no substitute for lived experience. We need people with years of experience to help reshape our healthcare systems so we can care for all of our patients and to redefine emergency preparedness for future events like the COVID-19 pandemic. Our health teams should routinely involve people from communities that bear the brunt of health inequalities. Currently, our healthcare system is designed by default for English speakers who have health literacy and digital skills and who have access to computers and / or smartphones – because that is the one who designs our systems. As we work towards change based on the lessons of the COVID-19 pandemic that we will continue to learn, we need to take this into account.
If you're a member of the communities hardest hit by the pandemic, you can help by sharing your experiences – what worked and what didn't – and advocating approaches to COVID with health care providers, community leaders, and through social media – 19 differences in healthcare. The topics I describe below are general topics from hospitals we have worked with, as well as what we have seen in our own healthcare system.
Take the necessary steps to build community trust
Trust is key to making messages about reducing the spread and impact of COVID-19 resonate with the community. However, trust is often shaped by historical events. Healthcare organizations need to delve deeper into how historical events have created suspicion of the communities they serve. Each ward's ambassador must be a trusted parishioner, and outreach must be done in the community, not just your health facility.
Invest time removing language barriers
Integrating interpreters during a medical visit, be it in person or via a virtual platform, is not easy. In fact, in most U.S. healthcare systems, it's not intuitive. At MGH we have seen this with the intercom system that is used to securely communicate with our COVID patients in the hospital and with the virtual visiting platform that is used for outpatient settings. Adding a third-party medical interpreter to these systems proved difficult. Contributions from an interpreting council and bilingual staff who were involved in redesigning workflows, telehealth platforms and electronic patient records helped.
Ensuring that teaching materials are available in multiple languages goes beyond translation. We also need to get creative with health literacy-friendly modalities such as video to help people understand important information. Our employees ideally include bilingual health care providers and employees who can communicate with patients in their own language. Otherwise the integration of interpreters into the workflow and telemedicine platforms is of crucial importance.
Understand that social determinants of health still influence 80% of COVID-19 health outcomes
COVID-19 disproportionately affects people who are key frontline workers and cannot work from home, cannot be quarantined through isolation, and rely on public transportation. So yes, social determinants of health are still important. If addressing social determinants seems overwhelming (for example, eliminating the shortage of affordable housing in Boston), it may be time to redefine the challenge. Instead of assuming that the health system will be burdened to solve the housing crisis, the question really has to be: How are we going to care for patients who have no accommodation and live in an animal shelter or surf the couch with friends and friends? Families or staying in cheap hotels or motels?
Use racial, ethnic, and linguistic data to focus mitigation efforts
Invest time improving the quality of racial, ethnicity, and language data in healthcare. In addition, stratifying quality metrics based on this demographic data helps identify health differences. At MGH, this foundation was already key to the rapid development of a COVID-19 dashboard that identified the demographics of patients on the inpatient COVID-19 floors in real time. At some point during our initial surge, over 50% of our patients in the COVID units required an interpreter as the majority were from the highly immigrant communities of Chelsea, Lynn, and Revere in the Boston area. This information was critical to our mitigation strategies and would help keep any health system informed.
Address privacy and immigration concerns
Most of the time, our health center providers, interpreters and immigration advocates tell us that migrant patients are reluctant to take part in virtual visits, enroll in our patient portal or come to our health facility because they fear that we will share their personal information with the immigration authorities and Customs control (ICE). We worked with a multidisciplinary group and our legal advisor to develop a low literacy script in multiple languages that describes these patients how we protect their information, why we are legally required to protect it (HIPAA), and in which Scenario we would share this with law enforcement (if there is a valid arrest warrant or court order).
Additional strategies include educating providers to avoid documenting a patient's immigrant status and educating patients about their rights and protections under the US Constitution. In short, this relates to the first point of trust building between the health organization and the community it serves.
Just caring is a journey, not a single destination. Only if we take decisive steps in this direction can we hope to achieve this and correct the course with new lessons from this pandemic.
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