Culturally Competent Care: Race/Ethnicity

Culturally Competent Care: Race/Ethnicity


– Good morning. My name is Sheila Cort, and I am Vice President of
Consulting at DiversityInc. Kaiser Permanente is a leader
in identifying, measuring, and eliminating disparities
in health and healthcare. Dr. Winston Wong has spent his career addressing health disparities
and will share with us today how Kaiser Permanente is looking at language barriers, cultural beliefs, low health literacy, and
institutional processes that may be challenges to equitable care. Please join me in
welcoming Dr. Winston Wong. (applause) – [Winston] Thank you, Sheila. That’s very nice of you,
and I’m very glad to spend a few minutes with you this morning talking about Kaiser Permanente’s journey and commitment towards eliminating health disparities in
how we promote wellness. We were discussing, during the
course of this presentation, I’ll pause at some appropriate
times in order for me to have a conversation with you. If you have any questions about some of the slides
during the presentation, we’ll have a chance to
have those questions in real time and discussion real time as opposed to just
waiting till the very end. I think one of the things
you’ll find in my presentation, and I was with you in the morning session, is Kaiser Permanente’s
a unique organization. It is not just a healthcare provider, it is not just a healthcare insurer, it is not just a physician medical group. It is all these things. When you look at all these components, it puts us in a unique position of how we address health disparities and how we think about
cultural competence. So I’m going to give you
spectrum of what that entails. This is one of my most favorite slides. As you can see, the photograph
is the important thing here. The photograph is a
picture of a physician, one of our earliest physicians
with Kaiser Permanente, who was talking to shipyard
workers in Richmond, California. The origins of Kaiser Permanente
go about 65 years ago, kind of started concurrently in the shipyards of Richmond, California, where ships were literally
built within 30 days because of the Henry J.
Kaiser Industrial Complex. The other part that was really critical in terms of the formation
of Kaiser Permanente was the construction of
dams in Southern California. The reason why I think this
picture is really compelling is because you see the ship in the back, and the physician is
really talking to workers who were contributing
25 cents per paycheck with regards to having
comprehensive healthcare, and he was talking about prevention of injuries in the shipyards. Secondly, the other reason why I think this picture is really cool is because of this picture
of this woman here. Women were a very critical
part of the workforce during World War II, building shipyards, and if you really look
at this individual here, she’s kind of the iconic
Rosie the Riveter. Indeed, if you go back to
Richmond, California now, there is a national
landmark that recognizes the contributions of
women and this workforce in the war effort in World War II. Suffice to say that Kaiser Permanente has its origins going
back about 65 years ago, and it is, as you can see,
affordable healthcare services and to improve the health of our members and the communities we serve. Now, I point out to you that
in Kaiser Permanente vernacular and if you were to be a part of the Kaiser Permanente
family, we most of the time use the term “members”
as opposed to patients, because we think we have an obligation to the members that
purchase Kaiser Permanente as an all-inclusive health plan, and I’ll discuss that in a moment. This is really what our
strategic vision is, adopted by our board of directors, is to be a leader in total health. When we think about total health, we think about it as a
state of complete physical, mental and social
wellbeing for all people: not just patients, and
certainly not just our members. We are committed to helping our members, our workforce, their families, and, by the way, Kaiser
Permanente has about 160,000 staff and physicians who
work for Kaiser Permanente, and 99% of them are also
members of Kaiser Permanente, so it’s a very interesting
opportunity for us to engage with families, members, staff around this total health vision. We do this by promoting clinical,
educational, environmental and social actions that improve
the health of all people. As you may know, Kaiser Permanente has most of its business in California. We have about 9.2 million members. 70% of that membership
resides in California, but we have other regions,
a total of seven regions: inclusive of Colorado; the Northwest, which we pretty much describe
as being in the Oregon area; and in Southern Washington
State; Atlanta, Georgia; the Mid-Atlantic, which
encompasses the district as well as parts of Maryland and Virginia; and then, our paradise, Hawaii. I described what our
total health vision is, and if you think about
this very seminal study by McInnis going back about 10 years ago, some smart people really
looked at what contributes to the total outcomes of
health of any given individual. When they looked at all the features and all the factors that
go into thinking about health and health
outcomes for individuals, you can see 10% of it is medical care. The vast contributors of
health outcomes have to do with personal behaviors,
family history and genetics, environmental and social factors. The fact is, when we provide
care in the hospital setting, in the clinical setting,
maybe we represent 10% of the equation in terms of the health outcome of
any given individual, which is very interesting because if you think about it that
way why do we have 99% of our resources captured
in the bricks and mortars of providing healthcare in clinical care? That’s a question and issue that all of our country has to deal with, but I do think that Kaiser
Permanente thinks about what ways do we interface
beyond the bricks and mortars of providing patient care and
how do we impact the question of personal behaviors,
environmental and social factors, and, to some extent, family
history and genetics? When we think about that equation, 10% medical care and 90% other features, then we have to think about what is our membership
currently look like? As you can see, this is our
current pie of membership, which is pretty much the leading edge of how the demographics in
this country is changing. 47% of our membership is Caucasian, but you can see 26% Hispanic, 14% Asian, 11% African-American. This is basically the browning of America. That’s I think why we’re even
at DiversityInc’s conference, how critical it is for
our company, our country, to think about what do we
offer and how do we interface with a demographic that is
diverse and rapidly changing? The other aspect about this is when you think about 9.2 million members, Kaiser Permanente has
this great opportunity to impact large class of
people that are comprising some of these major ethic racial groups. I work a lot in the Asian community. I’m actually a family practice doctor. I see patients still in a
community-based setting. Sometimes I share with folks that are working in the API community, Kaiser Permanente is actually caring for more than 1.1 million Asian-Americans, which is really an astounding figure. If you look at obviously proportionately to the other population groups, in the African-American
population we’re talking about 1 million African-Americans within the Kaiser Permanente membership. If you think about disparities, you think about cultural competence, we’re talking about large numbers, and we’re talking about seven regions. We’re talking about 16,000
physicians who are interfaced. We’re talking about how
we capture total health for a very diverse population
that represents big numbers. The other aspect that we
are soberingly reminded of is when you look at healthcare
disparities in this country, and this is really for the
nation, this is a sobering fact that when you just look at Black-White standardized mortality
ratios from 1960 to 2000, there has not been any
difference in terms of that difference going back
a couple of generations. If I showed this graph going back to the 1800s, it’d be worse. If we fast forward to
2010, I could tell you, it has not changed much from 1.4. It is a question our board
of directors, our company, our physicians, our staff think about, what does Kaiser
Permanente do to contribute to the question of a
stubborn and characteristic of healthcare delivery in this country? That 10% reflecting also on the 90% of the different factors, how do you really make a difference in terms of changing the trajectory, changing this stubborn fact
of where health, mortality exists in the United States
in terms of disparities? We can look at it from
a specific diversity and inclusion lens, and I
wanted to point out to you, this is something that we adopted just in the last couple of years as trying to capture the diversity and inclusion mission
that we have as respect to the total health strategy
that I just described to you. Care is about provision of care. It’s when you go into the clinic, when you go into the hospital,
what do we aspire to do? We do aspire to provide
the best care and service for all populations to
eliminate disparities in that magical interaction
between the healthcare provider, the healthcare team, and the individual. I think our speaker this morning described aspects of empathy, described aspects of not assuming things, described aspects of how
we think about people with different linguistic
and cultural beliefs, and we can get into that. I think we have a very thick
portfolio in that regard, but we don’t think of our
responsibility around diversity and inclusion as only within
the healthcare setting. We do think about our workforce, which I think the second panel dealt with, with regards to MBRGs, how
do we optimize diversity at every level and create
inclusive environments? As I showed you the pie chart
in terms of our membership, if I showed you a pie chart
in terms of our staff profile, it would be almost a mirror image. There’s always opportunity to
improve how our staff reflects the needs of our members in our community based upon whatever metrics
and whatever classification or segmentation that you want. The third aspect of this is marketplace. This is related to the fact
that we sell a product, we sell to a consumer group
in terms of an insurance plan around healthcare, as well
as a total health package. How do we make our programs attractive, accessible and affordable to
the communities that we serve? When we talk about affordability
now at Kaiser Permanente, we don’t talk about just
the fact that we want to be the most cost-competitive
product that any given consumer has to choose in a different community, especially in face of the marketplaces and the Affordable Care
Act, we think about the fact that healthcare is increasingly
becoming unaffordable for big segments of the U.S. population. When people have to choose whether to purchase health insurance or whether to put food on the table, we think we have a problem,
so the affordability is not a relative question for
us, it is an absolute question. Finally, with regards
to supplier diversity, this is a fact that
we’re a purchaser, too. In fact, our operating
revenue is $50 billion a year. What do we do in terms
of us thinking about how we reinvest in our communities? We’ve committed to become part of the so-called Billion Dollar Roundtable. We set upon this journey about
two years ago to make sure that we would purchase our
products with minority-owned, women-owned businesses
of at least $1 billion. We actually went beyond that
just in the last six months. So very proud of the fact
that all these things come together in terms
of being a provider, in terms of being a
consumer-focused group, in terms of being an employer, and then finally as a purchaser itself. Now, this is something
our Board of Directors adopted about six years ago. I can tell you that I was
pretty much in the middle of this discussion with
the Board of Directors. It had to be with the fact
that Kaiser Permanente knew that disparities had
existed in healthcare. It wasn’t so sure in terms
of whether healthcare disparities occurred within our system. Well, why do we say that? Because if you’re a
Kaiser Permanente member, you have a card and by all pretty much people have “equal
access into the system.” There was some question in
terms of whether disparities were replicated within a prepaid
prevention-oriented system where you become a member,
whether we had the same kind of disparities that were
exhibited in more conventional and traditional healthcare
provider situations. We can talk a little bit
about our journey in terms of making that argument that indeed disparities existed
within Kaiser Permanente. It’s a long story. It’s not a sordid story,
but it required us to be very deliberate
in making that argument. Through that argument,
the Board of Directors adopted this particular vision,
is that we will be a leader in eliminating disparities
in health and healthcare. We will do this by providing
equitable care to our members, targeting resources to areas of need in the communities we
serve and identifying and implementing strategies and policies that support equity in health nationwide, including universal access
to universal health coverage. This was before the Affordable Care Act. Again, I point out to you, do you see the word “patients” here? No. Okay? You only see “communities and members,” members being part of the community, and certainly, in any given family unit, you have folks that are
part of Kaiser Permanente and folks that are not
part of Kaiser Permanente. We really felt the equation is to engage in communities
in a comprehensive way to achieve this health disparities vision. Let me just pause here before I go to the next set of slides to
see if there’s any questions. I think there’s a microphone here, because we’re videotaping this. If you have any questions about our orientation towards
looking at health disparities and the fact that we’re not
just a healthcare provider but also a purchaser, employer, et cetera. Yes, ma’am?
– [Marni] Hi, Dr. Wong. Marni Telkamp with Novartis. Something that struck me, and
I hate to put you on the spot, but I wondered if you
knew the numbers for it. – [Winston] Yes?
– [Marni] When it comes to your strategy with supplier diversity, and you mentioned how you try to purchase from female small business owners, to what percent do you do that, and has it grown through the years? Do you happen to know that? – As, I can’t — I will say again, we have a
$50 billion operating revenue. I would say probably about five years ago, we were at about half a billion dollars, and then over the last two years that’s really accelerated
now to about $1.2 billion. Does that answer some of your question? Okay. Any other questions? Okay. All right. Well, let me get into some
of the clinical realms, because this tells kind
of an interesting story. As I mentioned to you, we had to present to our Board of Directors
what’s the real story of disparities within Kaiser Permanente? I was kind of in the middle of this mix in terms of generating this data. This is about colorectal cancer
screening by race-ethnicity. Are people all familiar
with the HEDIS Scores? You know what HEDIS is,
it’s basically a measure of the quality of health
plans across different metrics that are compared among hundreds, thousands of health
plans across the country. When we looked at with
colorectal cancer screening broken down by ethnicity
across Kaiser Permanente, the denominator for
colorectal cancer screening is defined by people who are 55 and older because that’s the criteria
that was established by HEDIS as being the break off point
where people really should be standardly screened for
colorectal cancer screening. You have to kind of work the
math, 9.2 million members, how many of them are 55 and older? It’s about 1.8 million folks, so we’re not talking about
non-substantial numbers again. We’ll go through this graph
a little bit in detail because it serves as the prototype of a couple of other slides you’ll see. This black line represents
90th percentile HEDIS, i.e., if you perform above
the 90% of this line, you perform better than 9 out of 10 other health plans
reporting on that measure. The green line represents
Kaiser Permanente’s all members. As I said, 1.2 million,
1.4 million members, how well do we do? You can see, we do very well. We’re above the 90th
percentile by a good margin with regards to all members. We broke this down for light blue being Asian-Pacific guy there,
dark blue being Caucasian, and purple being African-American, black, and Latino being this orange number. So, it’s very interesting. The question is, how many health plans have the opportunity to
look at such a large number, and then, secondly, break it down to the major ethnic and racial groups? This is what we showed to
the Board of Directors. I can tell you, I was in a
room with George Halvorson, who was as our CEO up to
the last year and a half, a man very much dedicated
to health disparities. He commented a couple of things. One is that we have a persistent lag among Latinos in colorectal
cancer screening. Even though we’re over 90 percentile, this is not acceptable
to have a persistent lag. Just as we have a
persistent lag in addressing health disparities with the
black-white mortality ratio that I described a few slides ago. One thing he also said, too, which I thought was very, very insightful, was that if you look at our Latino rate of colorectal cancer screening
in Quarter 1 of 2013, it’s actually higher
than the total membership was doing just a couple of years ago. This is a really important
point is quality improvement. There is an aspect of the
water level lifting all boats. On the other hand, if you don’t
accelerate towards improving a population group that you
see has a persistent lag, there’s always going to be a disparity. The other thing, too, which
I also mentioned to people, is this is not a pure math problem. This is a calculus
problem; why do I say that? Because the denominators of
Latino making the proportion of total KP membership
is not a static number. It is not always going to be 29%. It may be 40% in the next 10 years. Thus, you have to accelerate
your improvement with regards to Latinos and then how you
think about the engagement of all the ways that we leverage towards achieving health disparities reduction. This is a busy slide, but
I want to show you kind of how we’ve been able to
socialize this process. How many of you happen to
be clinicians in this room? Just a couple? Okay. I’ll just point out the big things. The orange here is the prevention goal. This is evidence-based in terms of what we know in the literature
as being efficacious in terms of screening
for colorectal cancer. For all of you who are
non-clinicians, I reinforce that colorectal cancer is a
preventable cancer, right? If we capture a polyp at its early stage, you could take it out and you will not have developed colorectal cancer screening probably for the next 7 or 10 years. All of you who are around
50, think about that. The interesting point, as you
look at these leverage points, potential indication is
lack of patient engagement, failure to respond, failure
to follow up, failure to test. I call these important
decision points for any patient to say whether I want to
go through this process of getting screened for colorectal cancer. These are important decision points, and any individual has to ask themselves, “Am I willing to submit to
do something in order for me “to get screened for
this particular cancer?” There’s so many different issues with regards to why a
person says yes or no, or why a family is in a
position of saying yes or no, relative to getting to
this prevention goal. These are the important
decision points here and this is what we do to socialize across the healthcare team
and across the health plan what do we need to do to accelerate the interventions needed
to address the gap that I demonstrated in the previous slide. I won’t go through these columns, Targets for Disparities Reduction and Specific Disparities
Reduction Strategies. You can see they row up into
getting to the evidence. At Kaiser Permanente, we believe there is evidence-based medicine that ever changes. We believe there’s a set
of scientific practices that will achieve the
ultimate clinical goal, but we have to customize approaches relative to these
important juncture points. What I’m going to show
in the next slide or so is to give you a demonstration of that. This is what we give to
patients with regards to getting a sample of
feces in the toilet bowl. I can start using graphic language, make you maybe a little uncomfortable, but I think it’s important. Why? It’s because all of our
families, need to say, all of us as individuals have
to deal with this eventually. Now, there’s a couple of things. When you look at this, can you follow it purely by the graphics
that are demonstrated? There is an extent that I have to say I think the graphics are pretty good. They don’t require people to have any capacity in a specific
written language, right? They’re graphic, okay? The other thing is that they’re not necessarily customized
culturally, right? One of the things that
we had to figure out, is this good enough and what
do you do to accelerate? I don’t have a good slide
because I was limited to a number of slides in terms
of what we do to accelerate. One was to have a Spanish
version of this that is on video, that demonstrates step by step in a Spanish video how
these things are done. The other thing is we had what
we call “toilet training.” What does toilet training mean? Among different centers in
our 34-hospital setting, we have about 400
different clinics as well, not every clinic, you’ll
see a toilet basin that is just in a special room. It is not the one you do your business in. It is not operating. It’s basically something we got from Home Depot and put it there. We went with our patients to
actually demonstrate with them. In many times, we invited a couple to say, “Tell us how you do it.” There’s some good stories about couples kind of arguing as to
how do you get the poo? But that’s kind of the
deliberation that has to occur for us to be able to activate
the whole decision process. There’s a number of other things to do, is when you think about
colorectal cancer screening, for a number of people it’s
a question of hygiene, right? It’s also a question of
why should I engage in this if you’re going to find something
that I don’t want to find? Are you looking for something
or screening for something? I think that is where some of the cultural competence comes in. That is where Spanish language comes in. That is where you have patient healthcare team members engage in a process. The other slide I don’t have for you because it’s really too busy, is that for any given medical center, we tell that medical center,
“What is your denominator “for the Spanish-speaking
Latino population “for you to achieve the
same level of performance “as you do for Caucasian members?” If we showed you a number
table, an Excel chart for the South Bay Health Center
in Long Beach, California, they could tell you, “Yes,
we have to achieve X number “of individuals in the
Spanish-speaking population “to get to the same level of
performance for Caucasians.” That is really important in terms of the quality improvement initiative. Before we go to high blood pressure, any questions about this
demonstration of how we think about this particular aspect of
colorectal cancer screening? – [Voiceover] Yup, I have a question.
– Yes? – [Voiceover] Where do you get your …? – There’s a microphone, we
have to get it on video. – [Voiceover] Hi. Where
do you get your data? – Okay, great question,
where do we get our data? We use our data on a quarterly
basis, which is pretty fast, considering how cumbersome healthcare is. One of the biggest opportunities we have is to employ Epic as our
electronic health record and it is the largest civilian electronic health record
now in the country. We harness this data and
we use self-reported data in terms of people’s identification
of race and ethnicity. There are some occasions where people do not report race-ethnicity, either because they don’t
come into the system, and/or the system is not
necessarily getting that data upon enrollment or when they interface. We use a complicated algorithm to impute the probability of a
given population group in fitting into one of
the racial categories. That’s about maybe 10% of
the equation, maybe 15%; 85% is now self reported. Does that answer your question? Yes, ma’am? – [Voiceover] Do you compare performance by your separate locations,
your different clinics, your different hospitals, and
what do you do with that data? – Yeah, great question. That chart that I showed you,
and this chart similarly, we report not only on the
regions, seven regions, the smallest region being about 300,000, the largest region being
about 3.2 million members. We also report by medical center. Generally, in a medical center, it’s ranged from anywhere
between 80,000 to 250,000. In some instances, we’ll get down to the level of “the clinic” when you’re talking about
a few thousand people. Each cut requires more and more resources and analytic power. Yes, any other questions? Great, thank you. High blood pressure is another important metric that we’re looking at. In fact, high blood pressure
and colorectal cancer screening were adopted by our quality subcommittee of the Board of Directors as
metrics that we would look at for looking at health disparities. One question that all
we have to deal with is when you look at health disparities, there is a list this long
that you could look at. Why did we look at high blood pressure and colorectal cancer screening? A couple of things: one, they align with our overall quality priorities; secondly, they’re important
relative to disparities that we see in these
respective populations, cancer in the Latino,
hypertension in African-American. Also, they represent different
spectrums of engagement. Controlling high blood pressure is a different set of engagements than it is for an individual to commit to a yearly colorectal cancer
screening laboratory test, right? It requires ongoing treatment of a condition that is chronic. I showed the prototype
of the slide set earlier. This is 90th percentile here. Look at how Kaiser Permanente
does, we do excellent. In fact, I’d like to point out,
this African-American line, if Kaiser Permanente was made up only of the 1.3 million African-American individuals in our membership, they would already be over
the 90 percentile HEDIS. However, having said that,
we know that the morbidity associated with hypertension
among African-Americans is particularly pronounced, particularly among people of working age. It is not acceptable, again,
for us to have a persistent gap that went as high as 7%
back just a few years ago. What we did was make a
commitment to see this relative or absolute difference
in blood pressure control from a couple of years ago
to 7% and reduce that by 50% over the next two years,
and we’ve gotten there. Nearly gotten there. I think this is 2013 Q3, we’re at 4.1% difference in the absolute gap. Now, how do you do that? Again, I’ll show you this slide, that’s a complicated algorithm. We know what the evidence is with regards to effective therapy from just a pill point of perspective, what you need to get in people’s bodies to control their blood pressure. On the other hand, we
understand that there are very important decision
points that take place with regards to whether
people change their lifestyle and whether people take their pills, because any of you here who take a pill for any chronic condition, you had to make a decision
as to whether I’m going to open up that pill everyday
and swallow some pills, having some faith and
confidence that overall my health’s going to improve
despite whatever side effects might have been described
to me by my physician. These are the decision points, and this is how we think
about cultural competency, decision support services, et cetera. Let’s see how much time I have. Because I can go through the
next few slides kind of — I need to advance the slide. Can you help me, anyone? (claps and laughs) – [Voiceover] That’s saying
last slide on the presentation. – Oh, really?
– [Voiceover] Yeah. – Really? Okay. All right. Well, I think you
can see my slides up here. I’ll show you some of these slides, okay? I don’t know what happened there. One of the things we did, and this was described also by a speaker, but we know what right medications, but we also know what
interactions have to take place. One of the things that we decided to adopt is the so-called AIDET approach. Do you know what AIDET is? AIDET is an acronym for a systematized way of how healthcare teams
relate to patients. It’s an acronym for,
number one, “Acknowledge.” Acknowledge the fact that the
person invested their time and commitment from their busy day to say that they wanted to see and
take care of their health. Number two is to “Introduce” one’s self, and introduce one’s self
by saying, “I’m Dr. Wong. “I’m going to be your
primary care physician. “I work with the
healthcare team to kind of “optimize your health, and
make sure I, Mrs. Jones –” Oh, hey great! What happened? Oh, someone coughed. (laughter)
Thank you very much. Introduce yourself and make sure that you have the proper introduction and don’t assume that
patients want to be addressed by their first name or nicknames. It’s Mrs. Jones until told otherwise. Thirdly, it is “Duration,” say, “I’m going to spend the
next 10 or 15 minutes “talking to you about your blood pressure “and what your concerns of that “and what’s important to you.” Then the E is to “Explain” why things, from your point of view,
might be done this way. We don’t say, “Let’s try
something,” because for certain population groups it
has a bad connotation. We say, “This is what
we know is effective.” Then finally, we make sure that we say, “Thank you for investing your time. “Let us know how we can continue “to support you on your healthcare goals.” Those are just a systematized
way of making sure that we socialize across
healthcare teams a way of connecting with patients on something as important as high blood pressure. That’s great, the slide showed up. The other thing which I
talked about is we look at this issue not just
within the healthcare walls. One of the issues is
how do you look at this from a community perspective? Because you spend 5 minutes, 15 minutes with a healthcare provider
on your high blood pressure maybe two to three times a year, whereas there’s many other things that happen in your daily life. What we said is look at who
our community partners are. In the last month, we introduced
a new grant partnership that we have with
American Heart Association that over the next three
years is addressing high blood pressure
among African-Americans. Our goal for all the communities we serve, not just the Kaiser Permanente membership, but 65% of participants will improve their blood pressure control to 140/90. Sixty-five percent is lower than Kaiser Permanente’s performance, but it’s still 15 points higher
than the general community, especially among African-Americans. What do we intend to do? American Heart Association
has a whole set of activities they have in terms of engaging clinicians, as well as providing
Internet-based, mobile-based support for patients to get support
for their behavioral health, as well as to monitor blood pressure. Just as importantly, and I
think I’ve showed the next side, is about engaging different
partners in the community. One of the major partners is
going to be faith communities. They do have a partnership with the hundred largest
congregations in the country and we will be amplifying the importance of blood pressure control. The other thing is
looking at new partners, and this is the barber shop opportunity where we know that young
African-American men go to the barber shop on a regular basis. As I like to point out,
it’s not about vanity. It’s about what young
African-American men are doing to invest in their well-being
as a man in the community and where they interchange
with other peer groups. We are looking actively
at how barbers can be the ambassadors of connecting people into getting their blood
pressure controlled. I’m very excited about that,
and you can see this testimony from one of the individuals that’s been part of this program
in Southern California. They have actually more
trust in their barbers than they do with their
primary care providers, and I don’t belie that. I think that’s the reality in where people get those kinds of social connections. The final slide I have is
with regards to looking at the broad breadth of how
Kaiser Permanente leverages its relationships and its
commitment in an all sided way. I talked a lot about the
clinical interactions, but I said that’s not the totality of it. The importance of it is also
about investing in schools, engaging our young people,
not directly around illness but around healthy behaviors. We have a thriving schools initiative, working with school-based health centers, working with hundreds of
schools across our regions to engage in healthy behaviors. We have farmer’s markets in about 40 of our different facilities
that set up shop once a week, so that the community can go shop and get fresh fruits and vegetables. We are actively promoting walking on a national platform
as the least expensive, the most accessible and
the most fun activity that anyone can invest in their health. We do a lot around our healthy workforce and engaging our workforce
itself in terms of taking up healthy behaviors
and being an exemplar of what it means to engage
and invest in one’s health. We have entered into — This is do a total health assessment. As I mentioned, we have
160,000, 170,000 employees. About 70% of the employees are captured under a labor management
partnership, union agreement. The union agreement includes components of X number of percent of folks will do a total health assessment and collectively we will lower BMI, we
will lower cholesterol in order to augment in terms
of the kinds of renumeration in revenue that goes
back to the employees. I think you’ll get a sense
of how we’re attacking all these things from an
all sided perspective, how it’s not just about
putting a piece of work around just cultural competence
in the clinical setting. We do believe in that, but also
think about the whole gamut of ways we leverage our
position at Kaiser Permanente. That’s a little bit of glimpse. I hope it gives you a sense
that it’s comprehensive in being a way of not
being just a provider, not just being an insurer, and
not just being a purchaser, but also an employer and an
active member in our communities and how we invest holistically
in creating total health. We have a few minutes for some questions. Thank you. – [Gene] Hi, I’m Gene
Hughes with Novartis. Has there ever been any thought around historically black
colleges and universities as an access point to
look at hypertension, look at some of these other illnesses as you’re looking at
focusing on that community if there’s an enormous population there? – Yeah, that’s a great suggestion. We do have an active partnership with The Satcher Health Leadership Institute based out of Morehouse, and
of course they’re part of the historically black
universities and colleges. What we do is we work with
different universities. We also have the KP UCLA
Center for Health Equity in terms of how to engage
not only the campuses but also the researchers
that look at community-based participation to look at the
levers around health equity. Thank you for that suggestion. We’ll continue to pursue that. – [Ryan] Hey, good morning. Ryan Parker, Robert Wood
Johnson University Hospital. I have a question about your journey towards being able to collect the data. We are in the journey now
of trying to get to where we can collect race-ethnicity
and language preference data, but what we’re learning is
that we’re not asking it the same way that many
systems that communicate into the main system that
runs the report for us. – Yes.
– [Ryan] So we’re in the process now of engaging in a Six Sigma
Project to take a look at all of the systems across the organization to move towards some standardization. What was your journey like? Was it a challenge for you? That’s my first question.
– Yes. – [Ryan] The second part of the question is how acculturated is
running this type of data and looking at the data
part of the organization? – Okay, so great question. With regards to our way of socializing the gathering of race-ethnicity data, we have a large diversity — well, we have a good
diversity inclusion department that works with every region in their own diversity
councils about how to do this. I think you’re learning,
the challenges about how to do this with the
frontline staff work who has to collect this
information is real. We actually had to develop a script that was endorsed by leadership to say this is the proper
way to get this data. The script goes something
along the line as, “We’re invested in your health. “We want to make sure we have
the best help for everybody. “That’s why we’d like to
ask you these questions. “You don’t have to answer
them, but we think it improves “our ability to provide service to you.” Then we have also trained staff to say, what if the person says, “Why
are you asking me my race? “I’m part of the human race.” Or, “Why do ask me about whether … “I’m multiple races.” Those are all legitimate
answers, to tell you the truth. We just have to work
with our staff to say, “This is the kind of response that we want “to give back to people that’s respectful “and at the same time
reflects our convictions “and our commitment towards
collecting this kind of data.” With regards to acculturation,
I’m not going to tell you that if you talk to a
Kaiser Permanente individual at the clinic right now that say, “Tell me about what you know
about race-ethnicity data.” They won’t necessarily know,
but I think our leadership is constantly percolating this downwards so that it’s also a part of how
line staff think about this. I don’t mean to be pejorative about that, because they’re the people who
really make the difference. I think leadership and echoing
the importance of this, as well as our board has
been really important. – [Ryan] Thank you. – [Forrest] Good afternoon,
I’m Forrest Coley. I’m with Sodexo, Senior Director. How has Kaiser Permanente
done, or have they done, any research as to the whys … – Yes. – [Forrest] … with the why,
why the folks do not want to participate and how
are you incorporating that in your speech or in your process
to change that perception? – Great question, we
actually have about — We have a research unit in
every one of our regions, and some are actually quite large. Our division of research
in Northern California is the largest research institute that is not affiliate of
an academic institution. We have a number of researchers that are looking at health disparities, and then particularly in cardiovascular. Dr. Alyce Adams, A-L-Y-C-E,
if you look at her work, she’s looking at what
are the system issues that get in the face of people being able to manage
something like hypertension. We self examine ourselves with this. One of the things that has
come out is what is the barrier of copays relative to
refilling medications, and whether there’s a differential impact of that particular factor with
regards to African-Americans as to other members in our organization. I use that as an example,
because that’s how we drill down, looking at delivery system issues relative to what we think purely
as the medical model. The other thing that I pointed out, that if you look at the literature around health disparities
over the last 10 or 15 years, more than 70% of those articles have to do with modifying individual
patient behavior as opposed to modifying systems to address
the patients where they are. I think our journey at Kaiser Permanente is to look much more
specifically at the system issues that are not about modifying
a patient’s behavior patterns, but modifying the system to fit that patient’s behavior choices. I hope that answers part of your question. There’s another question there? Yes? – [Gary] Hi, I’m Gary Butts from the Mount Sinai Health System. Thank you for sharing what
Kaiser has been doing, and I think it’s a great model. Clearly, it demonstrates why
you guys deserve to be amongst the top in DiversityInc, and
this is really quite good. It really reflects
engagement from the ground, all the way up and clearly requires the vision and foresight
of your leadership. Let me ask a question
around connecting the dots, if indeed you are, between
workforce diversity … – Yes. – [Gary] … and outcomes
for diverse populations. If so, what can you
share with us about …? – Yeah, great question. One of the slides I was
asked not to share with you, (laughs) our staff live in these communities. When you do a GIS mapping of where the disproportionate burden of diabetes, hypertension, obesity are, you see that, relative to the hot spots with regards to low income and marginalized
population groups. Maybe that’s not news to you, but the thing that was really
revealing to us is that we showed the same map
relative to our own employees and to the best extent capture their disease prevalence based
upon where they live, and the map was overlaying each other. It’s when you look at
where our own staff live and how much the environment and the social determinates
factors into their own health, this is where it gets really
serious for us in terms of what do we as an employer to actively engage in
investing in those communities through these different things, as well as to support people
and their families to be able to make the best choices
the easiest choice as well? We’re on this journey
where if I said to you, “We’re 550,000 folks self insured,” that’s a lot of the margin. We actually have to
think about how we invest in making sure that things like diabetes, things like obesity and
things like hypertension are controlled even within
the staff and families, of which about 5%, 7% of our
membership actually is part.

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