Maria is a 66-year-old Hispanic diabetic who receives her primary care at MGH Chelsea. At a recent visit, Maria’s hemoglobin HbA1c (a measure of diabetes control) was 12.60, far above the more normal level of about 7. Maria was referred by her doctor to the diabetes “coach,” a multilingual, bicultural lay person trained to identify barriers to care management and assist patients in addressing them. After several counseling sessions, the coach learned that Maria was taking one of her medications “only when I feel my blood sugar is too high,” and was not taking her other medication at all because “it makes me dizzy.” Maria was overweight and her diet was high in carbohydrates and cholesterol. She was not exercising and reported often feeling depressed and “in the blues.”
After working with the coach, Maria began taking her medications regularly and eating better. She cut down on carbohydrates and started eating more vegetables and fruits. She also ate more frequently in small portions. Due to her arthritis, exercise was a challenge for Maria, but she managed to walk most days. In just a few months she lost 30 pounds. After follow-up sessions with the coach, Maria feels very pleased with her progress, she is more confident, and has “more days happy than in the blues.” When last seen by the coach, Maria’s hemaglobin HbA1c was 7.70.

Unequal Treatment, a study on racial and ethnic disparities in health conducted by the Institute of Medicine (IOM) (2002), confirms that disparities in health care exist. The study concludes that there are not only disparities in health outcomes, but also disparities in quality of care provided to minorities even when controlling for socioeconomic status, comorbidities, stage of presentation and other factors. Maria’s coach is a key member of the Chelsea
Diabetes Disparities Initiative, developed in response to identified disparities between
white and Hispanic diabetics in Chelsea in both rates of testing as well as measures of
control for those tested. The Chelsea program is just one of a range of initiatives to emerge
from the MGH Committee on Racial and Ethnic Disparities in Health Care.

The Disparities Solutions Center
Joseph L. Betancourt, MD, MPH, Director

MGH launched the Disparities Solutions Center (DSC) in 2005, under the direction of Dr. Joseph Betancourt. The DSC is dedicated to the development and implementation of strategies that advance policy and practice to eliminate racial and ethnic disparities in health care. The Disparities Solutions Center achieves this mission by:

• Serving as a change agent by developing new research and translating innovative research findings into policy and practice.
• Developing and evaluating customized policy and practice solutions for health care providers, insurers, educators, community organizations and other stakeholders.
• Providing education and leadership training to expand the community of skilled individuals dedicated to eliminating health care disparities.

The Disparities Solutions Center is the first center of its kind in the United States.  While other disparities centers exist, The Disparities Solutions Center is the first to be based in a hospital, with a focus on moving the issue of disparities in health care beyond research and into the arenas of policy and practice.  The Center will serve as a national, regional, and local resource for hospitals, physician practices, community health centers, medical schools, other health professions schools, health plans and insurers, consumer organizations, and state and local governments.

The Disparities Solutions Center has received an initial funding commitment of $3 million from MGH and Partners HealthCare, as well as $1 million from the Robert Wood Johnson Foundation. Housed within the MGH/Partners Institute for Health Policy, the Center is affiliated with Harvard Medical School’s Department of Medicine and Health Care Policy and the MGH Division of General Medicine.

Now in its second year, the Disparities Solutions Center has many significant accomplishments to report:

• Continuing to build a diverse, talented team of faculty and staff
• Beginning a DSC Associates Program, now with 18 area researchers and clinicians with a broad set of interests and experience all dedicated to addressing racial and ethnic disparities
• Providing leadership to MGH projects focused on identifying and addressing disparities, especially in diabetes, colorectal cancer screening, and mental health
• Conducting the first Disparities Leadership Program, targeting leaders from hospitals, health plans, and community health centers from around the country
• Developing partnerships to address disparities across the country, including in Puerto Rico and New Orleans
• Leading several web seminars on prominent, timely technical issues and research findings
• Welcoming the first Aetna/DSC HealthCare Disparities Fellow, as well as several medical students for summer research activities
• Publishing 16 articles and chapters in peer-reviewed publications
• Playing a role in the media, with quotes from the DSC staff in several newspapers, trade newsletters and television/radio programs
• Sponsoring several local health fairs and events to provide support for educational programs, community awareness activities and commending leadership for addressing disparities
• Participating in the Disparities Action Network, an organization convened by Health Care for All to address disparities issues throughout the state of Massachusetts
• Launching a new interactive web site at www.mghdisparitiessolutions.org
• Supplementing seed funding with an additional $865,476 for Year Two activities

The MGH Committee on Racial and Ethnic Disparities in Health and Health Care
Joseph R. Betancourt, MD, MPH
Joan Quinlan, MPA

In late 2002, Mayor Thomas Menino convened the Boston teaching hospitals to explore their role in eliminating disparities in health and health care among racial and ethnic minorities in the city. These disparities are well documented nationally and locally. As part of that effort, Peter Slavin, MD, President of MGH, created the MGH Committee on Racial and Ethnic Disparities in Health Care (the Disparities Committee) in the spring of 2003, and charged it with identifying and addressing disparities wherever they might exist at MGH. The committee is co-chaired by Dr. Joseph Betancourt, a senior research scientist in the MGH/Partners Institute of Health Policy, and a member of the Institute of Medicine’s (IOM) committee that produced Unequal Treatment, a definitive look at health disparities in America, and Joan Quinlan, Director of the MGH Center for Community Health Improvement. In 2005, MGH announced the formation of the Disparities Solutions Center, directed by Dr. Betancourt.
The Disparities Committee, comprised of senior leaders from throughout the hospital and physician’s organization, formed subcommittees and launched an ambitious agenda. Below is a summary of accomplishments.

Quality Subcommittee

Charge: To develop methods for ongoing quality measurement of outcomes stratified by race and ethnicity and to design quality improvement initiatives to address when issues are identified.

Projects and Accomplishments

Disparities Dashboard. The Disparities Dashboard, first published in 2006, provides patient demographics and utilization, data regarding interpreter services, clinical quality measures for both inpatient and outpatient services by race/ethnicity, and patient experiences with care for different racial and ethnic groups.  Work for the second iteration of the Dashboard is now underway.  The Dashboard is produced under the direction of Gregg Meyer, MD, Msc, senior vice president for quality and safety and Elizabeth Mort, MD, MPH, director of Clinical Care Management and Decision Support, with Sarah Lenz, Senior Project Specialist of the Clinical Care Management Unit, and Amy Giuliani, MPH, Team Leader for Data Analysis and Reporting, among others.  Robin Weinick, PhD, of the MGH Institute for Health Policy, was instrumental in the initial design of the dashboard. 

Medical Policy: On May 3, 2006, The Medical Policy Committee, upon the recommendation of the MGH Committee on Racial and Ethnic Disparities and staff of The Disparities Solutions Center, amended the Quality Policy on Data Management to include the following statement:

Racial and ethnic disparities:  In order to assess and address racial and ethnic disparities on an ongoing basis, all relevant performance improvement data should be collected and stratified by race and ethnicity.

This change will enable additional measures of disparities in quality of care within the MGH to be evaluated.

Quality Rounds. Quality and Safety Rounds were started at the MGH in 2002 with the goal of identifying key issues that could jeopardize patient safety or lead to medical errors. To achieve this goal, a doctor-nurse team routinely visits an inpatient floor and meets with multi-disciplinary members of the care team.  In 2003, a specific question focused on disparities was incorporated into the Quality and Safety Rounds. To date, the issue of language barriers has been identified with greatest frequency, but other issues raised in response to this question also include issues of understanding and acceptance of varying cultural traditions (particularly around gender issues, religion, and visiting policies and issues of access, particularly in the ambulatory settings). The process alone has raised awareness and sensitivity on the part of the staff.

Interventions. Disparities identified as a result of the Disparities Dashboard are now being addressed through several culturally competent interventions.  Diabetes and colorectal cancer programs are in place at the MGH Chelsea Health Center (read more about these programs in the Chelsea section of this report). The Disparities Solutions Center is working with MGH Psychiatry on a pilot project to provide culturally competent psychiatric care and consultation for patients with multiple chronic illnesses as part of the MGH CMS demonstration quality improvement project.

Patient Experience and Access Subcommittee

Charge: Assess the experience of care at the MGH for patients of color, develop and implement action plan to address disparities.

Projects and accomplishments

Patient Survey.  A 400 patient telephone survey of minority patients (including 136 cross-sectional) was conducted in two languages (English and Spanish) to determine minority patients’ experiences of care at MGH. While the perception of equal quality of care for minorities is better at MGH than in society in general, there is still a significant gap, and almost ten percent of minorities could cite a specific example of unfair treatment, which they believed was based on race or ethnicity. In addition, two key themes were found: 1) The treatment, satisfaction and training of front line staff has a large impact on patients perceptions and experiences of care and 2)  It is not just language that is important, but also the overall sensitivity and compassion demonstrated by providers matters as well. The survey was developed and analyzed by Karen Donelan, Sc.D., and Nakela Cook, M.D., M.P.H.

Multicultural Advisory Committee.  The Multicultural Advisory Committee (MAC) has met quarterly since its inception on October 25, 2004. The committee is comprised of leaders, patients and their families from various minority communities, and is charged with advising MGH on minority patients' experience of care and perception of the hospital in minority communities. As a result of MAC recommendations, the MGH recently began a lecture series targeted at improving the service of front-line staff. This committee is co-chaired by hospital president Peter Slavin and senior vice president Jeanette Ives Erickson and staffed by Joan Quinlan, MPA, and Nakela Cook, MD, MPH.

Education and Awareness Subcommittee

Charge: Develop plans to educate/raise awareness among the entire MGH community of disparities and the factors that contribute to disparities.

Projects and accomplishments

Awareness. The Education and Awareness Subcommittee has created a comprehensive communication strategy that focuses on increasing internal awareness of the issue of racial and ethnic disparities and the work of the MGH Committee.  This includes 11 articles in the MGH Hotline (a weekly newsletter for staff, employees, volunteers, visitors and friends of MGH), one in The Fruit Street Physician (a newsletter for MGH physicians), and three posters that have been displayed throughout the campus. 

Continuing Education. Committee leadership or membership is responsible for at least 4 presentations at grand rounds and leadership meetings per year and a semi-annual Disparities Forum.  The upcoming Disparities Forum will be held on January 23rd in the O’Keefe  

Chelsea Diabetes Management Program
Eddie Horta, M.A., MHC, Diabetes Coach

The Diabetes Management Program, launched in spring 2006, seeks to improve the care of all diabetics at MGH Chelsea and to reduce disparities in care between white and Hispanic patients.  This initiative was launched in collaboration with an initiative sponsored by the Mass. General Physicians Organization and the Disparities Solutions Center.

There are well documented disparities in diabetes care nationally. African Americans are 38 percent and Latinos 33 percent less likely than Whites to receive standard care for diabetes.  At MGH Chelsea, approximately one third of Latino diabetics did not have routine tests within the preceding nine months, and when they had the tests, nearly twice as many Spanish-speaking Latinos (41 percent) showed poor diabetes control compared to English-speaking Whites (23 percent).

The pilot program provides: individual coaching using a culturally competent, multilingual diabetes coach to assess specific factors that may lead to non-adherence to medication regimens, diet, and exercise plans; tailored education and interventions designed to address these issues; telephone outreach to patients to increase diabetes-screening frequency; and group education in English and Spanish through which patients share experiences and tips on diabetes self-management.

An evaluation of the program seeks to measure improvements in patients self-management; learn whether the program improves diabetes management for Spanish-speaking patients more, less or the same as for English-speaking patients; and determine barriers that patients have in taking care of their diabetes, such as lack of understanding of the disease, lack of family support, financial barriers, and perceived barriers to care due to immigration status.

Program Data

• The Diabetes Coach has worked with over 320 diabetics providing over 1400 individual and phone coaching sessions.
• The program implemented diabetes bilingual self-management education classes for over 100 patients.
• Preliminary research data shows significant improvements in diabetes management for patients in the program.  From a sample of 133 randomly polled patients,

• Latinos (100 patients) had a 13 percent  reduction in a key measure of diabetes control
• Whites (21 patients) had a 12 percent  reduction
• Patients of other races (12 patients from Brazil, Cape Verde, Morocco, Somalia,  etc) had a 21 percent reduction

The Colorectal Cancer Screening Program aims to improve colorectal cancer screening (CRSS) for all eligible patients at MGH Chelsea, and to decrease disparities in CRCS rates that exist between Latino and White patients, as well as in low income and non-English speaking populations in Chelsea.

The Colorectal Cancer Screening Coordinator works closely with the Gastroenterology (GI) Department at MGH Boston and with Adult Medicine providers to facilitate the referral and communication between the MGH specialty department and the patients. The coordinator provides education on colon cancer screening options and explores and works on addressing the individual patient’s barriers to colon cancer screening.  The coordinator provides education on colonoscopy procedures and also provides emotional support. The coordinator serves as a patient navigator to schedule and remind patients about appointments, help them access insurance, explain instructions for their test preparation and translate written material.  The coordinator also accompanies patients to their GI appointments and interprets during the appointment if needed.  Screening results and patient contacts are documented in a program data base.   The program also seeks the help of MGH Chelsea interpreters/outreach workers to reach other non-English speaking patients, primarily Arabic, Bosnian Portuguese, and Somali patients.

The program was launched with support from an MGH Clinical Innovation Award to Sanja Percac-Lima, MD, PhD.

Program Data

• Since the program began in January 2007, it has been offered to 409 patients between the ages of 52-79 years old.
• The navigator has contacted 310 patients.
• 92 patients had colonoscopies.
• 56 patients completed and returned Fecal Occult Blood Test cards (FOBT).
• To evaluate efficiency of the program, a randomized controlled trial (RCT) was carried out from January to October of 2007:

• All (1223) patients 52-79 old at Chelsea HC overdue for CRC screening were randomized to intervention (n=409) or usual care control (n=814) group.
• Over the nine-month period, intervention patients were more likely to undergo CRC screening than control patients (27 percent versus 12 percent). Most of the difference among intervention and control patients was attributable to significantly higher colonoscopy rates (21 percent versus 10 percent).
• The higher screening rate resulted in the identification of 10.5 polyps and 0.24 cancers per 100 patients in intervention group vs. 6.8 polyps and 0.12 cancers per 100 patients in the control group.