In this section, we provide resources that can support the development of equitable environments for care of people with diabetes.
Creating an equitable environment for care is critical to reducing disparities in diabetes outcomes among Medicaid beneficiaries through our collaborative. Topics include a framework for integrating health equity priorities into quality improvement (Resource F1.1), screening and referral for addressing social drivers of health (Resources F2.1-F2.4), understanding and addressing racism and inclusive resources for diverse populations (Resources F3.1-F3.6).
Dashboard Data Measures:% of adults with diabetes and A1C > 9 screened for social needs in the last year, % of adults with diabetes and A1C > 9 who screened positive for a social need and referred to address that need. ***We will also be collecting demographic data to be able to measure and conduct PDSAs on other process and outcome measures to identify and address disparities. Please work with your QI coach to establish a disparity aim and determine which measures you will follow for that aim
While it is essential that we work to improve diabetes quality outcomes, like A1C, for all our patients, creating an equitable environment of care through prioritizing measurement of disparities and interventions designed to address the causes of those disparities is also critically important. Social drivers of health, interpersonal and systemic racism, and lack of inclusion contribute strongly to disparities in diabetes outcomes.66-68
F1: Health Equity Framework
To narrow persistent disparities in health outcomes, it is helpful to have a practical framework to design interventions that have the potential to advance equity. The PETAL framework69, which stands for Prioritize health equity, Engage the community, Target health disparities, Act on the data, and Learn and improve, provides a structure for integrating health equity into a learning health system. This framework includes real-world examples to build infrastructure within your practice project to address disparities.
F1.1: Using the PETAL Framework to Advance Health Equity
Cardi-OH’s Capsule provides information on the PETAL framework that can be applied to integrate health equity into a learning health system or quality improvement efforts and provides examples of how to apply an equity framework to a QI project in primary care.
F2: Identifying and Addressing Health-Related Social Needs
We know that 80-90% of the modifiable factors contributing to health are related to social, environmental, and structural context.70 These factors, referred to as the social drivers of health, often contribute to the root causes of health outcome disparities in diabetes66 and screening for and addressing social needs is one potential pathway to reducing diabetes disparities. The resources below include validated tools to screen for social needs in the primary care setting, as well as resources around referral to social care providers for patients who screen positive for social needs and desire assistance connecting to resources.
F2.1: Summary of Social Needs Screening Tools
This resource provides a list of tools used in primary care settings to screen for social needs and shares lessons learned from the implementation of social needs screening.
F2.2: Ohio Network of Certified Pathways Community HUBs
This document provides contact information for your primary care practice to connect with a Pathway HUB within your area of Ohio. Pathway HUBs assign a community health worker to work with a client to address their health-related social needs. See map.
F2.3: The EveryONE Project Assessment and Action
American Academy of Family Physicians has additional resources for identifying and addressing social drivers of health exist on their website.
F2.4: Community Resource Links
There are multiple sites that provide resources available to assist providers in finding community resources for patients to address health-related social needs including:
United Way 211
Get assistance for your social service needs 24 hours a day.
Findhelp.org
Financial assistance, food pantries, medical care, and other free or reduced-cost help.
Unite Ohio
A coordinated care network to connect to much-needed wraparound supportive services.
F3: Anti-Racism and Inclusive Resources for Diverse Populations
Recognizing that there are many groups impacted by bias and disproportionately by health disparities including immigrant and refugee communities, LGBTQIA+ communities, migrant and agricultural workers, people with disabilities, and people with a history of justice involvement. Below are selected resources about anti-racism, LGBTQIA+ communities, people with disabilities, and culturally and linguistically appropriate services. Please reach out to your Quality Improvement Coach if other resources are needed by your practice to better serve your populations.
F3.1: Allegories on Race and Racism
In TEDx Emory video, Dr. Camara Jones discusses racism definitions and ways to address it.
F3.2: The 21-Day Antiracism Challenge
The challenge includes suggestions for readings, podcasts, videos, observations and ways to form and deepen community connections.
F3.3: Anti-Racism Learning and Reflection Tool
University of California designed this tool to facilitate learning, self-reflection, and conversations with respect to anti-racism and is a rubric that allows team members to assess where they are as far as supporting anti-racist practices in their team/workplace.
F3.4: Improving Care for LGBTQIA+ Patients: Creating an Inclusive Practice
This Cardi-OH resource offers seven domains for the provision of excellent care for LGBTQIA+ people and includes recommendations for clinicians and building a clinical environment supportive of LGBTQIA+ patients.
F3.5: Increasing Physical Activity and Exercise in Adults with Disabilities
This Cardi-OH resource details special considerations and recommendations for physical activity for adults with disabilities.
F3.6: National Culturally and Linguistically Appropriate Services (CLAS Standards)
These are a set of 15 action steps intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services.