Data collection and engagement are pivotal parts of any organization’s efforts toward health equity.
Dr. Geoffrey Leung, Riverside University Health System Ambulatory Medical Director, delves into how to collect sexual orientation and gender identity (SOGI) and race, ethnicity and language (REAL) data, while sharing other options if those metrics aren’t a place for you to start. As he reminds us, “You actually work on equity every day. And equity is embedded in all of the patient care that we do.” Leung goes beyond the data to talk about the importance of questioning assumptions, how to get buy-in, and insights from Riverside’s own efforts.
GEOFFREY LEUNG: Hi, my name is Geoffrey Leung, and I serve as the ambulatory medical director at Riverside University Health System (RUHS).
CCI: Hi, I’m Suzanne Samuel, and I am a consultant working with CCI. Thank you so much for being here. Dr. Geoffrey Leung also supports the primary care providers at the RUHS medical center clinics and 12 RUHS community health center sites and serves as the chair of family medicine. This year. Geoffrey has also been working closely with RUHS public health in supporting COVID efforts across Riverside County. Dr. Leung enjoys working on the integration and transformation of care delivery in order to provide the community with the best care possible. Thank you so much for being here. Given the many ways to describe this important work, how do you define health equity?
GEOFFREY LEUNG: We think of health equity in a few different ways. We would like to make sure that different groups of patients are all able to access our healthcare in a way that is easy and convenient. We also wanted to make sure that those patients are receiving the types of supports that are necessary, and those types of supports may vary depending upon Individual needs. And then finally, we look at outcomes, to see in terms of things like blood pressure control or diabetes control, are different groups of patients, having different outcomes? And are we doing the best to support all of our patients?
CCI: How do you know when you have achieved health equity?
GEOFFREY LEUNG: I think that’s a great question. I think, you know, health equity is a goal that we’re all aiming for. And that end point may always be sort of further than maybe one or two steps away from where we’d like to be. I think it, it really depends on where we are as an organization. So, for us, for example, right now at Riverside, health equity is about looking at different types of patient groups and making sure that if barriers that are specific to one group or another, that we’re trying to address them, that we’re trying to tailor our care, that we’re trying to provide care that in a way that is culturally competent. But I think probably for all of our organizations, health equity is an ongoing journey, and it’s not just about helping people with access or helping people with supports. But it’s also helping people ultimately live the healthiest lives possible.
CCI: Tell us why equity matters to you at your organization, both personally and professionally.
GEOFFREY LEUNG: I think equity is something that resonates with a lot of us who, especially those who are serving an underserved or vulnerable community, and because many patients from those types of communities often face hurdles that others may not have to face — whether it’s financial, educational, social, discrimination. You know, we who are committed to caring for patients in underserved settings, often find ourselves spending a great deal of time and effort trying to help with those barriers, which can ultimately help with someone’s physical health and overall health.
CCI: Health equity strategy at a big level and scale might be out of reach for some community clinics who are part of the CCI community. Many are focused on small scale changes that they can test and implement, and some struggle with where to start. If you were just starting on this journey toward health equity, where would you begin?
GEOFFREY LEUNG: It definitely depends on where your organization is, but we do think there’s a bite size way, an achievable way that each organization can start. The first is, you know, you can take a look at your population or your outcomes and start to break it down by different groups. So, whether that’s by women compared to men, whether that’s by different age group. And then definitely, you know, we would advocate for taking a look by race, ethnicity, by sexual orientation, by gender identity. And especially for, you know, critical areas that you’re looking at if you see significant disparities or differences that don’t make sense or that, you know, are significant, those are probably opportunities to start exploring. And, you know, tackling health equity in this way doesn’t mean that you will automatically be able to eliminate disparities. And oftentimes, you know, we may have a knee-jerk reflex. We may think because we see a difference in diabetes care for two different groups, you know, the answer is more diabetes care or more coaching or more pharmacy support. But we would probably urge you to start by talking with your stakeholders. So, whichever groups you, you see disparities in first we think that having conversations, focus groups, site exchanges, and being able to listen to those groups will probably provide the highest yield opportunity to learn about measures that might be effective or strategic to start with.
CCI: And so, what would be a step from there? I think you outlined the first two, right? Looking at the data, talking to people, and then where where’d you go from there?
GEOFFREY LEUNG: Yeah. So after, after talking with your stakeholders and learning about, you know, what your stakeholders may feel are the most important issues with the most important barriers. And it’s helpful to bring that back to your teams, your frontline staff, and sort of have a discussion or brainstorming about that. It’s rare that you would be able to address everything that comes out of a focus group or that you hear from stakeholders. But then, you know, choosing those one, two or three things that maybe the teams feel would be the highest yield, that would be the most practical, that would be doable. And we do believe that often times, we’re very ambitious in what we want to do, which is great. But we have to be careful to not let that ambition sort of prevent us from making those first few steps and choosing something that is low hanging, high yield, achievable, and that can be measurable. I think are all really critical. So for instance, if you’re hearing from a focus group that one of the things that really needs to be addressed is transportation or is having more linguistically and culturally sensitive staff members. But if you don’t have a way of measuring that, or if that’s not something that you’ve already started to look at in terms of your data, that may actually be a very difficult place to start. So choosing places where you’re already doing measurement, where you’re already looking at data, that tends to be an easier place because then you can actually evaluate and assess to see whether changes you’ve made have made a difference.
CCI: Thanks for those very tangible examples. And can you give an example of something at Riverside that you started with that was low-hanging fruit or achievable, as you just described to be so important?
GEOFFREY LEUNG: Yeah, absolutely. So, transportation actually, for us, was something that we thought was solved for most of our patient population. We had taken a lot of great effort into putting into place transportation for those who may have difficulty getting to our clinics or our hospital. We partner with a managed Medi-Cal plan that is very proactive and supportive and provides transportation as long as visits are known in advance. And so, we really felt like we had a solution that covered all of our patients. Moreover, we felt like we had a process where we were asking about transportation upfront and we thought that we were catching this. But as we spoke with some of our patients in this case who were having difficulty controlling their diabetes, we realized that we had gaps in our system — either gaps in knowledge from a patient standpoint or a staffing standpoint. And we discovered that many patients who had access to transportation support, either through their health plan or through our system, weren’t aware of that. And that in some cases our team members were thinking that patients might’ve been non-compliant or non-adherent, maybe not wanting to come back for a visit, and not realizing that transportation was actually the main barrier. Sometimes it’s coming back to an issue that you’ve already felt like you’ve solved. But for us at Riverside, we’ve actually had to approach transportation more than on one occasion, and doing this discovery work and looking at disparities, we realized that again we had a gap in our system. And then in terms of after we did reeducation with our staff and our patients, we discovered that we had a great uptake in the use of the transportation services that were already being offered. And that did make a big difference for us because we had patients that we thought were lost to follow up, who were not wanting to come back in. We didn’t know why they hadn’t come back out after three or six months. And suddenly we were seeing them back in the clinic.
CCI: So how did you do it?
GEOFFREY LEUNG: So again, that process of looking at maybe a metric or measure where you have a significant difference between groups, something that you might not expect. I think again, the second step, really talking to those stakeholders or those patients and making sure that you’re listening. And then, I think it’s also tough, but dropping all previously held assumptions. So, you know, if we had gone into some of these discussions and said, “Well, you know, transportation is not an issue because we know we’ve taken care of it,” we probably wouldn’t have gotten further. But really hearing from our patients that that was an issue and then I’m coming back to our staff and sort of doing that validation, you know, I think all of that was important. So really starting from scratch with any of these conversations, not having any previously held conceptions or assumptions and listening first to the patient, I think are all highly valuable.
CCI: You talk about the importance of questioning assumptions. Do you have a system for doing that?
GEOFFREY LEUNG: I think we’re still trying to figure this out. How do you make sure that you’re constantly challenging what you think you know, and especially in areas where you may feel something has already been covered or maybe there’s a gap that you sort of excused. We really need to be good about constantly coming back to the things that are not working in our system for our patients. And I think sometimes we become accustomed to the challenges either in our system or the challenges that our patients face, and that causes us to actually miss seeing some of these things. So, I don’t know if that makes sense, but really having low or no tolerance for things that are not working. Setting our expectations high. Not allowing ourselves to say that, you know, this is this way because our community is financially more challenged or because we don’t have enough resources or because we don’t have enough people. I think, for us, it’s having to say we need to do the best for our patients. Every single time. And if we’re not doing that, what do we need to take another look at? What do we need to reevaluate? And what do we need to question in terms of our own assumptions? And finally, what can be learned from our patients?
CCI: Would your advice differ for a public hospital versus a small clinic. And I know you have both at Riverside. So just curious if, when you’re looking at disparities and where did it begin, you take different approaches? Or is everything you said applied to regardless of size?
GEOFFREY LEUNG: I think these are good steps that no matter if you’re a small clinic or a large hospital. We do know that with large hospitals, sometimes you have the benefit of infrastructure or teams that can help coordinate or do this work. But really, it’s that same process. And if you miss those steps in terms of listening and talking with the key stakeholders, including your patients and your frontline staff, then you can easily put into place solutions that may not be highly beneficial.
CCI: The buy-in is so important for equity work. You’ve talked about this a little bit, and we’re in a national moment when people are talking about equity important ways, but it’s still a topic with a lot of emotional resonance and including recognizing the impact of this year’s events on many of our colleagues are Black, indigenous, and people of color. What strategies have you seen at Riverside or elsewhere of how to get leaders engaged around equity — both for internal strategy efforts and for patient facing efforts?
GEOFFREY LEUNG: That’s a big question. I think we’ve seen a variety of strategies with different groups. So, our county board of supervisors did make a statement regarding racism as a public health crisis. That can definitely be helpful if you have that within your context. We do know that race and ethnicity can be highly charged and emotional topics. You know, one approach that we’ve taken at Riverside is to really try to break down the social determinants and sort of the determinants of health that we want to support with our patients. So, we we’ve actually created a tool called a “whole person health score assessment,” which is a holistic way of measuring health. And the reason why that helps us is it actually looks at things like not only physical and emotional health, but things like resource utilization; socioeconomics in terms of finances, education, employment; things like ownership and activation; and finally, nutrition and lifestyle. And while all those pieces do not necessarily shout race or ethnicity or disparity, what it allows us to do is to do an individualized or tailored assessment of each individual or patient, and then support them in a tailored or custom way. And we think that that’s actually one way that we can try to close disparities for different types of groups that may evolve and change over time. We may focus on certain racial groups. We may focus later on sexual orientation or gender identity, but those different groups may change. What we hope is that we have an approach that can be standard and support disparities work regardless of which groups we’re trying to help bring to equity.
CCI: When you’re starting out and you need to get leadership engaged, what would you recommend?
GEOFFREY LEUNG: So, if you’re trying to get leadership engaged with topics regarding race, ethnicity, or racism, I think there’s both a logical part of a persuasive argument, as well as an emotional piece. We’ve always found it helpful to have data behind us, but I think what’s most powerful is usually starting with a patient’s story. So, if you have a patient story that that really articulates the vision that you’re trying to get at, or the challenge or the problem, we know that can always be very humanizing. It’s much easier to sort of connect with and understand, and people will often retell that story. We’ve found that to be very powerful. And, and of course, if you can get patients to tell it in their own voice, from a first-hand perspective, we think that that’s even more engaging.
CCI: Can you share a story that you’ve used at Riverside around this work?
GEOFFREY LEUNG: So, in terms of race and ethnicity, I think we have stories on a daily basis. I think the most common type of story that we hear is patients come to us for what they think are typical medical issues. So, you know, they come to us for their diabetes, for their high blood pressure, for their heart disease, for their chronic ailments. And they feel like there’s certain topics they can talk about and certain topics that maybe are not meant for a doctor’s office. You know, and trying to look at people holistically, we’ve really tried to give people permission to talk about those other issues that are important in people’s lives. And also help people understand that these other aspects of people’s lives are really interconnected with physical health. So, I think common stories are really, whenever we get into the personal lives of people, struggles that often they’re dealing with, either with relationships, self-confidence, emotional health. People telling their stories about how they’re they feel like they’re being treated or perceived, and, you know, being able to be acknowledged or recognized as sort of human individuals who are suffering through difficulties. Then when teams are able to connect in that way, it oftentimes opens up a whole new channel for dialogue. That can definitely occur in the areas of race, but oftentimes it’s also things that that may feel mundane. You know, it may be about employment. It may be about stressors. It may be about finances. It may be about living situation. And you ultimately realize that it’s, it is actually all tied back to disparities.
CCI: It sounds like staff are super important to get engaged from the very beginning.
GEOFFREY LEUNG: I think engaging staff in this dialogue about equity is very similar to the way we would engage leadership. Usually if you have a patient story or an individual that maybe even a staff member knows because they’ve taken care of this patient, I think that tends to be more powerful and palpable.
CCI: How are you seeing organizations addressing health inequities today in ways that might be different from even a year or two ago?
GEOFFREY LEUNG: Organizations now have health equity as part of their vocabulary. And one, two, three years ago, I think talking about race, ethnicity, sexual orientation, gender identity were often topics that many staff were uncomfortable with. When we had to do our initial training years ago for front desk staff, even in terms of asking about sexual orientation and gender identity, we found that we had to do a lot of practice conversations. As much training as you do, if people aren’t used to having conversations about sensitive topics, we found that that could be an unintentional deterrent for being able to capture data that we thought was vital. Because all of these topics are much more commonplace, much less taboo, they’re sort of routine and part of standard work now for many organizations. I think the next challenge is, now that we’re collecting this information, what do we do with it? And that’s really the big question. In terms of our mission to serve our communities and to take care of our patients, how do you take this information and make the biggest impact possible? And it may actually be in ways that we don’t expect. Again, we’re going to start with looking at the numbers that we typically measure. We’re going to look at blood pressure and diabetes, which are really important. But our guess is that as organizations start diving into all of this work, it really will ultimately propel you upstream. We’ll be finding that we’re dealing with many more social and economic factors, that we’ll be talking about attitudes and beliefs. We’ll be talking about how you sort of heal and connect communities. And those types of things may have the biggest impact on our population health outcomes, even more than some of the traditional metrics that we tend to focus on.
CCI: I do want to talk more about data, but before we go there, I’m so interested in what you just said about some of these social determinants. Are there any examples you can share as something that you have started drilling down into more or a place where you are focusing efforts?
GEOFFREY LEUNG: At Riverside we’re, we’re fortunate to have, first of all, the teams to support our complex care patients, and those teams include care managers and care coordinators, behavioral health managers and specialists, as well as a community health workers. We also have a health coach program that supports our patients, most commonly with chronic diseases like diabetes and high blood pressure, helping patients set self-management goals and meet those goals with those programs. We’re fortunate to have additional support for our primary care providers and teams. Because of this added support, we’re able to dive into more of the personal issues that patients are facing and then provide additional support. And what we mean by that is, if you have a typical uncontrolled diabetic patient, the standard responses increase medications or add medications. So many times, that doesn’t work because we’ve missed something critical in that patient’s life — so whether it has to do with ownership and activation, that patient’s education about their own disease process, or whether there’s a social or economic barrier, for instance, joblessness, caregivers stress, something else that’s going on. If you’re not addressing those things, then that conversation about changing medications may be sort of a moot point. So, we’ve really focused looking at what are some of the emotional health needs? What are some of the ownership and activation needs of patients? Definitely because we’re doing a holistic assessment of our patients, we are doing more referrals to our nutritionists and dieticians, and those are all areas that we’d like to further develop and mature. We’re also trying to do more work in terms of connecting patients with community resources as well. And figuring out how to do that and integrate that with your electronic health record system, I think can be both challenging, but we think will be highly beneficial.
CCI: One obstacle that we’re hearing with working on health equity is around capturing data on equity. And we’ve talked some about this. Especially in light of telehealth, how do you ask patients about race and ethnicity to collect that race, ethnicity, and language data, also known as REAL data, and the sexual orientation and gender identity data, known as SOGI data? How do you ask them in a way that helps capture good data to inform care delivery, but also allows care teams to educate the patient about why you’re asking in the first place and how that data is going to help patients?
GEOFFREY LEUNG: You know, the last part of your question is really the beginning of the answer. In our scripting with our patients, we always try to start off by saying the reason why we’d like to ask the following questions is so that we can know you better and provide better care for you. And we typically find that with that approach, most patients are very understanding. I think when you don’t preface questions about sensitive information, that’s when you may have people who either feel defensive or a little caught off guard. You know, “Why are you asking me about these very personal issues?” But again, if you preface it in the way that, you know, “In order to be able to take better care of you, support you in the best way possible, we want to know about you as an individual. We want to be able to tailor your care, and if you help us with these questions, we think we’ll be able to do a better job.” Framing it in that way I think it’s usually reassuring for patients and can make that conversation easier.
CCI: What are some of the strategies you use in helping staff get comfortable with doing this and make sure that the data they were collecting was going to be high quality data?
GEOFFREY LEUNG: I think this is a, an ongoing conversation and definitely not a one event and done. I think the initial conversations have to be about the questions that might typically come from patients. You know, you could expect them from your frontline staff as well. “Why is it so important that we need this? You know, what is the purpose? These are things that maybe I’m not comfortable talking about with most people. Why do you need to know?” And making sure that your staff have that understanding and buy-in first, we think is important before you even start talking about the scripting with patients, because really you need to convince your staff about the importance of it before they can convince patients how important it is to collect that data. I think the other pieces for us, we found that really, it’s something that you have to keep on talking about. So, you may feel like you’ve done a training. You may feel like you’re getting pretty good data and you need to somehow either spot check that or monitor it or revisit. But probably any part of a plan to collect a REAL data, or race, ethnicity, and language data, needs to include a component where you’re revisiting and going back and sort of checking to see if the things that you think are happening are continuing to happen.
CCI: Your whole person health score gets to that holistic element of assessing other forms of data. If you weren’t in a place to implement such a rigorous structure, what might be a way to start to capture some of that information as data, beyond SOGI and REAL data?
GEOFFREY LEUNG: I think there is a tension between capturing data that can fit in a discrete data field in your electronic health record and capturing very meaningful data that can sometimes come from open-ended questions. And so I think if a clinic site or hospital is sort of not ready to dive into an entire holistic assessment, getting back to questions that we may often think of as chit chat or part of soft conversations, those can actually sometimes really become the meat of a visit. So true questions about, how are you doing? How have things been for you? We know that you’ve been taking care of your sick mother all of these months. That must be really difficult. Can you tell me how that’s been for you? Providing patients with an opening like that. Or if it’s for brand new patient, oftentimes it can just be starting off with things like, can you tell me a little bit about your work? What do you enjoy about it? Who you live with at home? How are things at home? What do you enjoy the most in your life? What are some of the things that are hardest for you to get through during your day? And how do you feel about your relationships with the people you live with or the people you love? Oftentimes these other types of open-ended questions will almost give that permission to patients to talk about things that they might not have planned to talk about during a visit. And that can be a good way to get started. It will not give you discreet data, but it will start giving you insight into maybe areas of a patient’s life that really could benefit from additional support.
CCI: You’ve noticed that community members reach out to providers and the health system at Riverside in different ways than you have been reaching out to them. What was occurring and how did you figure that out?
GEOFFREY LEUNG: Even the COVID pandemic has, has been very insightful for us. Probably like many of our audience members, Riverside, we used a traditional sort of a brick wall approach, where we expect patients to come into our clinics in our hospital and we care for those individuals in the best way possible. I think that’s one way of connecting with patients, but definitely patients have different ways that they think are the most convenient for them. And coming into a clinic physically is not always the easiest way. What we’ve sort of learned again is that for many patients that have virtual care, whether it’s by telephone or by video, is often more convenient and more patient centered. And so, we think one benefit of the pandemic is that it’s really helped accelerate efforts and are doing a better job, extending those types of virtual visits to patients. And, you know, being able to be reimbursed for them definitely it makes that much more sustainable. But I think it’s a constant learning for us because we always have assumptions about what we think our patients want and what we think patients need. And we really need to challenge ourselves by continuing to go back to our patients and our community and ask them what it is that they need and what it is that they feel like with certain.
CCI: What advice would you have liked to receive when you started on the journey to health equity at Riverside?
GEOFFREY LEUNG: I wish someone had told me that, although equity sounds like a big and unachievable goal, it sounds like something very ambitious and something that only certain groups that are very sophisticated might be able to tackle, I wish someone had told me at the beginning, you actually work on equity every day. And equity is embedded in all of the patient care that we do. For all those who believe in and supporting vulnerable populations who believe in social justice, we’re actually doing things in each of our visits to support equity and we just may not realize it. And really equity is in another way, it’s about individualized care. You know what, at the end of the day, I have this individual in front of me who needs care. What does this person need the most? And thinking beyond a medicine or a surgery procedure, is there anything else that if we could help this person with would changed the trajectory of their life and their health? All of that has to do with equity. And I think what we’re trying to move towards is figuring out how to systematize this, how to capture the type of equity work that’s done in terms of data and make it easier for all of the members of our team to work on it, and support equity in a language that makes sense to them.
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