Driving Health Equity into Action: Hospital Planning and Delivery

Bob Gardner
UHN Psychiatry Rounds
January 28, 2011

© The Wellesley Institute
www.wellesleyinstitute.com

1. health disparities in Ontario and Canada are pervasive and damaging
2. but these disparities can be addressed through comprehensive health
equity strategy
3. equity strategy can be driven into action within the health system
through
• equity-focused planning
• aligning equity with key system drivers such as sustainability and quality,
and priorities such as ER, ALC, diabetes, etc.
• building equity into ongoing performance management and service delivery
• investing in promising interventions, and pulling them together within a
coherent and coordinated overall strategy
• enabling innovation through sharing and building on front-line and local
initiatives, evaluation, and organizational learning
4. focus today is on a key setting for implementing this overall strategy --
equity-focused planning and delivery in major hospital – in context of
psychiatric care in particular

www.wellesleyinstitute.com 2

• there is a clear gradient in health in which people with lower
income or socio-economic status, or facing discrimination,
racism or other lines of social exclusion, tend to have poorer
health
• plus major differences between women and men
• in addition, there are systemic disparities in access to and
quality of care within the healthcare system
• not just unfair and unjust, but health disparities make it more
difficult to achieve provincial priorities such as ALCs, ER,
diabetes, etc, and contribute to avoidable costs
• enhancing health equity has become a clear priority – from the
Province to LHINs to many providers
• that’s why we need strategies, tools and best practices to build
equity into effective system and service planning


• Lowest-income neighbourhoods had a significantly higher
prevalence of probable depression than highest-income
neighbourhoods (risk ratio - 1.36).
• Women and men living in the lowest-income
neighbourhoods were also somewhat more likely to use
OHIP core mental health services and to receive ECT and
much more likely to be hospitalized for depression.
• However, individuals living in the lowest-income
neighbourhoods accounted for lower OHIP core mental
health care costs, which suggests they either made fewer
visits or received less expensive services than those living
in the highest-income neighbourhoods.
Source: POWER Study Vol 1 Exhibit 5a.9


inequality in how long people live
• difference btwn life expectancy of top and bottom income
decile = 7.4 years for men and 4.5 for women
+ inequality in how well people live:
• more sophisticated analyses add the pronounced gradient
in morbidity to mortality → taking account of quality of
life and developing data on health adjusted life
expectancy
• even higher disparities btwn top and bottom = 11.4 years
for men and 9.7 for women

Statistics Canada Health Reports Dec 09


• clear research consensus that roots
of health disparities lie in broader
social and economic inequality and
exclusion
• impact of inadequate early
childhood development, poverty,
precarious employment, social
exclusion, inadequate housing and
decaying social safety nets on health
outcomes is well established here
and internationally
• real problem is differential access to
these determinants – many analysts
are focusing more specifically on
social determinants of health
inequalities

www.welleseyinstitute.com
8

• Health disparities or inequities are differences in health outcomes that
are avoidable, unfair and systematically related to social inequality and
disadvantage

• This concept:
• is clear, understandable and actionable
• identifies the problem that policies will try to solve
• is also tied to widely accepted notions of fairness and social justice

• The goal of health equity strategy is to reduce or eliminate socially and
institutionally structured health inequalities and differential outcomes

• A positive and forward-looking definition = equal opportunities for good
health
• Equity is a broad goal, including diversity in background, culture, race
and identity


• the point of all this analysis is to be able to identify policy and
program changes needed to reduce health disparities
• but health disparities can seem so overwhelming and their
underlying social determinants so intractable → can be paralyzing
• think big and think strategically, but get going
• make best judgment from evidence and experience
• identify actionable and manageable initiatives that can make a
difference
• experiment and innovate
• learn lessons and adjust – why evaluation is so crucial
• gradually build up coherent sets of policy and program actions –
and keep evaluating
• need to start somewhere – and focus here is on building equity
into best hospital and psychiatric care

© The Wellesley Institute 11

• even though roots of health disparities lie in far wider social
and economic inequality
• how the health system is organized and how services and
care are delivered is still crucial to tackling health disparities
• consistent theme in WHO, EU and all the major international
reports and in the many countries that have developed
comprehensive multi-sectoral strategies to reduce health
disparities
• in all of them, transforming the health system is an
indispensable element, including:
• reducing barriers to equitable access to high quality care
• targeted interventions to improve the health of the poorest, fastest
• up-stream investments in primary and preventative care directed to
most vulnerable
• delivering a full continuum of services in coordinated way at
community/local level


1. it’s in the health system that the most
disadvantaged in SDoH terms end up sicker and
needing care
• equitable healthcare and support can help to mediate the
harshest impact of the wider social determinants of health on
health disadvantaged populations and communities
2. in addition, there are systemic disparities in access
and quality of healthcare that need to be
addressed
• people lower down the social hierarchy tend to have poorer
access to health services, even though they may have more
complex needs and require more care
• unless we address inequitable access and quality, healthcare
and community support services could make overall
disparities even worse


• goal is to ensure equitable access to high quality
healthcare regardless of social position
• can do this through a two pronged strategy:
1. building health equity into all health planning and delivery
• doesn’t mean all programs are all about equity
• but all take equity into account in planning their services and outreach
2. targeting some resources or programs specifically to
addressing disadvantaged populations or key access barriers
• looking for investments and interventions that will have the highest
impact on reducing health disparities or enhancing the opportunities for
good health of the most vulnerable


while health disparities are
pervasive and deep-rooted, they
can be changed through policy and
program action
comprehensive strategy developed
in 2008 for Toronto Central LHIN
many recommendations have been
acted on
other LHINs are also prioritizing and
moving to address health disparities


• align equity with system drivers:
• equity is pre-condition to quality and efficiency agendas
• essential part of high-performing health system, now enshrined in new
Excellent Care for All act
• align with system priorities:
• can’t solve wait times or chronic conditions without addressing equity
• build equity into priority setting and service planning
• for example, by identifying and addressing critical access barriers and
populations with unmet needs
• build into performance management:
• explicit equity targets and incentives
• cascading through the system -- Prov → LHINs, agencies, etc.→
providers
• within providers → into specific programs and depts.


• need to make equity one of driving priorities for health system and
reform
• equity and a population health focus are among key principles enshrined in
new Excellent Care for All Act = opening and context
• need clear provincial strategy for equity:
• implicit from MOHLTC, but promised ten year strategy has not been released
• need strategic coherence across health system in approach to equity
• LHINs, CCACs, and other coordinating agencies need to prioritize equity –
and many have
• cascading down to all providers prioritizing equity in their service
delivery and resource allocation
• UHN: equity incorporated in Strategic Plan and cross-hospital Health
Equity Council has been established
• the Council has set out ambitious and progressive goals for the coming year

• hospitals are developing Quality Improvement Plans
• will be reporting every year
• equity can be developed as one of dimensions to report on
• similarly, build equity into your accreditation processes
• and into internal processes -- balanced scorecards,
dashboards and other planning tools
• at UHN: 2011-12 goals of Health Equity Council and included
in refresh of equity plan include:
• each program will include at least one health equity indicator in its
Quality Report to Board
• developing a gender equity indicator for each program


• cost-effectiveness and safety:
• reducing language barriers to good care through better interpretation
can reduce mis-diagnoses and over-prescriptions → enhanced quality
and cost effectiveness
• ER:
• one key pressure on ER wait times and ALC is inappropriate use by
disadvantaged populations
• part of the solution = better access to primary care, better referrals
and linkages with community care
• highlights the importance of partnerships with community agencies
• quality and patient-centred care:
• taking lived conditions/experience into account – meaning equity and
diversity → essential to high quality patient-centred care


• addressing health disparities in service delivery and planning
requires a solid understanding of:
• key barriers to equitable access to high quality care
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• this requires sophisticated analyses of the bases of disparities:
• i.e. is the main problem language barriers, lack of coordination among
providers, sheer lack of services for particular populations, etc.
• which requires good local research and detailed information – speaks to
great potential of specific analyses within provider organizations and
community-based research
• involvement of local communities and stakeholders in planning and
priority setting is critical to understanding the real local problems
• and requires an array of effective and practical equity-focused
planning tools


1. quick check to ensure equity is 1. simple equity lens
considered in all service
delivery/planning
2. take account of disadvantaged
populations, access barriers and 2. Health Equity Impact
related equity issues in program Assessment
planning and service delivery
3. assess current state of provider 3. equity audits and/or HEIA
organization
4. determine needs of communities 4. equity-focused needs
facing health disparities assessment
5. assess impact of
programs/interventions on 5. equity-focused evaluation
health disparities and
disadvantaged populations


• analyzes potential impact of program or policy change on health
disparities and/or health disadvantaged populations
• generally designed for planning forward – as easy-to-use tool to
ensure equity factors are taken into account in planning new services,
policy development or other initiatives
• but experience here and in other jurisdictions identified other uses:
• for strategic and operational planning
• for assessing whether programs should be re-aligned or continued
• more generally, discussions around HEIA provide a way to ensure
equity is incorporated into routine planning throughout an
organization
• increasing attention to potential – from WHO, through most
European strategies, PHAC, to Ontario


• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN
and Wellesley Institute
• refined the one-page template
• and developed a new workbook
• HEIA is being used in Toronto Central and other LHINs
• Toronto Central has required HEIA within recent funding application
processes for Aging at Home, and refreshing hospital equity plans
• been used in many settings relevant for you:
• all programs within a sister hospital are undertaking HEIA
• has been used in various setting over last few years – e.g. community-
based psychiatric program in suburban area
• one goal of UHN Health Equity Council = pilot HEIA in 2
programs

• a promising direction several LHINs have taken up is to require providers
to develop equity plans
• hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation in TC
• and other providers in Central
• CHCs are developing sector-wide plan in GTA
• these plans are designed to:
• identify access barriers, disadvantaged populations, service gaps and opportunities
in their catchement areas and spheres
• develop programs and services to address those gaps and better meet healthcare
needs of disadvantaged communities
• these provider plans have the potential to:
• raise awareness of equity within the organizations
• build equity into planning, resource allocation and routine delivery
• pull their many existing initiatives together into a coherent overall equity strategy
• build connections among providers for addressing common equity issues


http://www.torontoevaluation.ca/tclhin/index.html


• clear consensus from research and policy literature
and consistent feature in comprehensive policies on
health equity from other countries =
• setting targets for reducing access barriers, improving
health outcomes of particular populations, etc
• developing realistic and actionable indicators for service
delivery
• closely monitoring progress against the indicators or
targets
• recognizing that what gets measured, matters
• disseminating the results widely for public scrutiny
• interesting international and local work on
developing evidence-based equity indicators
hospitals can use

http://www2.massgeneral.org/disparitiessolutions has valuable
resources, including Improving Quality and Achieving Equity:
A Guide for Hospital Leaders

CRICH has reviewed research and UHN is developing its own
indicators © The Wellesley Institute

• where targets and indicators get tied to deliverables and
incentives
• all hospitals sign Service Accountability Agreements with
LHINs that govern flow of funds
• can build specific expectations and deliverables into these
agreements
• will vary by community and provider -- but could include:
• undertaking appropriate equity-focused planning to identify areas
where access to services is inequitable and developing plans to
address barriers and gaps
• stratifying quality indicators by equity – e.g. readmission rates is
common objective
• equity angle is to reduce any inequitable differences in
readmission rates by language ability or neighbourhood


• precondition for all this planning, monitoring indicators, and assessing
progress against objectives and targets is reliable data on:
• ethno-cultural background, language, income, sexual orientation
• service use and health outcomes, differentiated by these equity and
determinants of health variables
• hospitals have been using postal code data as proxy
• when hospitals in Toronto Central began working on their equity plans it
became very clear that they simply did not have the necessary data to do
equity-driven planning
• a workshop was held on what kinds of data on equity and diversity are
available, how the existing data sets can be effectively used, and what further
types of data are needed
• three hospitals are collaborating on developing plans on how to collect and
incorporate equity data -- UHN stays connected to project
• UHN will be analyzing how to enhance data collection – e.g. language
preference at ER


• target services to specific areas or populations:
• those facing the harshest disparities – to raise the worst off fastest
• or most in need of specific services
• or the worst barriers to equitable access to high-quality services
• this requires sophisticated analyses of the bases of disparities:
• i.e. is the main problem language barriers, lack of coordination among
providers, sheer lack of services in particular neighbourhoods, etc.
• again, need solid data within the institution
• also need good local research and detailed information – speaks to great
potential of community-based research to provide rich local needs
assessments and evaluation data
• involvement of local communities and stakeholders in planning and priority
setting is critical to understanding the real local problems

31

• huge number of innovative programs underway across the
province and City
• e.g. psychiatric and other services in homeless shelters
• community mental health services geared to specific ethno-
cultural and immigrant communities
• LHINs identify priority populations and providers can
identify those most relevant to them
• initiatives underway at UHN include:
• Toronto Western Family Health Team is focusing on homebound
– typically frail and isolated seniors – and young and new
immigrant families
• programs have been enhanced to support people with
Thalassemia and Sickle Cell Disorder


• one of identified equity challenges across Toronto Central LHIN
hospitals – and within UHN -- is language:
• identified as critical issue in first hospital equity plans and other Toronto
Central planning → major project to develop more systematic coordinated
approach to interpretation in downtown hospitals
• at UHN:
• identified in first equity plan → improved access to language line –
including portable phone lines → increased use and satisfaction
significantly
• expanding in-house interpretation call centre in key languages of your
patient community
• not just better quality, but research shows access to interpretation can
contribute to safety, appropriate drug and service utilization, etc.
• UHN sees cultural competence training as essential underpinning
of interpretation and other quality services


• same principles drive partnering with community agencies to
meet needs of specific communities
• e.g. Concurrent Disorders Services partnering with Native Child
and Family Services:
• recognizing systemic disparities facing Aboriginal peoples
• goal is to ensure traditional health techniques are integrated with
clinical best practices
• and that people can move seamlessly between community and
hospital care within a flexible client-centred model
• well-established network of community mental health providers
and organizations is key resource to be linked to
• working in community-based cross-sectoral collaborations is
widely seen to be a key way to address the impact of social
determinants of health


• all of this equity planning loops back to quality
• patient-centred care means taking the full range
of people’s specific needs into account
• social context and living conditions people face are
part of this
• when people face adverse social determinants of health →
can increase risk of mental health challenges and illness
• → fewer resources to cope (from supportive social networks,
to good food and being able to afford medication)
• providers and programs need to know this to
customize and adapt care to needs and contexts
• more intensive case management, referral planning and
post-discharge follow-up

• quality standards are especially important to most disadvantaged
populations
• how to forge quality standards that reflect individuals’ and communities’
diverse perspectives and needs
• e.g. what does quality psychiatric care look like from point of view of poor
older recent immigrant?
• highlights the need for more community-based forms of research and needs
assessment, and critical importance of community engagement and
connections
• one danger of overall quality agenda and performance management is:
• guidelines could be too clinical or academic, or monitoring too quantitative
• not so easy to apply to complex interventions such as ongoing support for
health disadvantaged populations with complex mental health needs


• Ministry, LHINs and research bodies need to fund and enable evaluation
– not just as a tacked-on expectation in accountability regimes
• need to figure our what interventions and approaches work, in what
contexts and why
• at a program as well as system level:
• can’t just measure activity – number or % of pop’n that participated in
a program or received particular services
• need to measure health outcomes – even when impact only shows up
in long-term
• need to assess reach -- who isn’t signing up or getting the services
they need?
• need to differentiate those with greatest need = who programs most
need to reach and keep to have an impact


• huge number of front-line initiatives already addressing
equity across city and province
• many hospital programs, CHCs, mental health, community
care and support, community organizations based out of
specific ethno-cultural and other communities
• promising practices such as ‘peer health ambassadors’ to
provide system navigation, outreach and health promotion
services to particular communities
• but
• experience and lessons learned are not being shared
systematically
• potential of promising interventions is not being realized

• to drive equity-focused innovation and effective interventions, we
need to be able to:
• collate and analyze all the useful intelligence gained from
equity-focused planning
• capture and share information on local initiatives, and build on
local front-line insights
• share the resulting knowledge across regions – and beyond
• assess the most promising initiatives or directions rigorously
• scale up promising initiatives across the province where
appropriate
• need to create forums and infrastructure for this innovation
knowledge management
• LHIN and provincial responsibility, but forums such as this are
also key


• health disparities are pervasive and deep-seated – but
can’t let that paralyze us
• do need a comprehensive and coherent health equity
strategy – but don’t wait for perfect strategy
• think big and think strategically – but get going
• build equity into strategic priorities, align with quality
agenda and system priorities, embed in routine
planning and performance management
• and build equity into front-line planning and delivery
where you practice
• no magic blueprint -- experiment and innovate -- and
build on learnings and success


• these speaking notes and further resources on
policy directions to enhance health equity, health
reform and the social determinants of health are
available on our site at
http://wellesleyinstitute.com
• my email is bob@wellesleyinstitute.com
• I would be interested in any comments on the ideas
in this presentation and any information or analysis
on initiatives or experience that address health
equity


1. look widely for ideas and inspiration from jurisdictions with comprehensive
health equity policies, and adapt flexibly to Canadian, provincial and local needs
and opportunities;
2. address the fundamental social determinants of health inequality – macro policy
is crucial, reducing overall social and economic inequality and enhancing social
mobility are the pre-conditions for reducing health disparities over the long-
term;
3. develop a coherent overall strategy, but split it into actionable and manageable
components that can be moved on;
4. act across silos – inter-sectoral and cross-government collaboration and
coordination are vital;
5. set and monitor targets and incentives – cascading through all levels of
government and program action;


6 rigorously evaluate the outcomes and potential of program initiatives and
investments – to build on successes and scale up what is working;
7 act on equity within the health system:
• making equity a core objective and driver of health system reform – every bit
as important as quality and sustainability;
• eliminating unfair and inefficient barriers to access to the care people need;
• targeting interventions and enhanced services to the most health
disadvantaged populations;
8 invest in those levers and spheres that have the most impact on health
disparities such as:
• enhanced primary care for the most under-served or disadvantaged
populations;
• integrated health, child development, language, settlement, employment, and
other community-based social services;


9 act locally – through well-focussed regional, local or neighbourhood cross-
sectoral collaborations and integrated initiatives;
10 invest up-stream through an equity lens – in health promotion, chronic care
prevention and management, and tackling the roots of health disparities;
11 build on the enormous amount of local imagination and innovation going on
among service providers and communities across the country;
12 pull all this innovation, experience and learning together into a continually
evolving repertoire of effective program and policy instruments, and into a
coherent and coordinated overall strategy for health equity.


The Wellesley Institute advances urban health through rigorous research,
pragmatic policy solutions, social innovation, and community action.


Driving Health Equity into Action: Hospital Planning and Delivery

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