Diminishing Disparities by Transforming Cardiovascular Care: A Stepwise Approach

Illustration: Lee Sauer

"We must use time creatively, in the knowledge that the time is always ripe to do right."

― Martin Luther King Jr.

Cardiovascular disease (CVD) remains the number one cause of death in the U.S. alone and "claims over 650,000 lives annually and puts a huge strain on the health care system and the economy, both in terms of cost of care, and lost productivity."¹ Of that number, people of color have disproportionately suffered increased morbidity and mortality from CVD, reminding us that social injustices and racial inequities continue to influence disease burden and our overall healthcare system. Research from the American Heart Association (AHA), the American College of Cardiology (ACC), National Institutes of Health and other major healthcare organizations in the U.S. has consistently shown that race still influences the quality of care that minorities receive despite the incredible innovation in cardiovascular (CV) care. An excellent article published in Circulation: Cardiovascular Quality and Outcomes connects issues of race, racism, CVD and barriers to appropriate cardiovascular care. This article provides a thorough analysis to help improve care and educate the future healthcare workforce.¹

This blog is not intended to rehash or provide education about ways that our healthcare system has underserved certain communities. Instead we want to consider practical implementation of the recommendations to address the proverbial elephant in the room. As individual humans, we can become too overwhelmed with guilt, dismay and frustration to make changes – the issue is daunting and bigger than all of us. Healthcare is always on the government’s agenda but has either political party been willing to intervene to effect substantial change? Costs are still rising while payments are still decreasing and we must do more with less every year.

Individual political parties, health systems or practices cannot change the world on their own. But a collective of caring and innovative teams can make improvements. This is not a problem for a select few. The cost burden is on all of us. The following operational considerations can be implemented as a framework for the transformation of CV care for underserved populations.

Step One: Adopt a Population Health Management Approach

"Equality is giving everyone the same pair of shoes. Equity is giving everyone a pair of shoes that fits."

― Unknown

• Be thoughtful about onboarding new patients.
  • Ask questions! Collect the patient’s and family’s preferred methods of communication to discuss care.
  • Include and encourage family involvement in care plans when possible.
  • Implement a detailed social and family history repository.
    • Depending on past medical history (PMH), evidence-based guidelines may dictate a more aggressive care pathway (i.e., fast track to imaging and/or intervention).
    • Use evidence-based guidelines on genetic predisposition and include this information in the direction of the care pathway.
  • Begin to collect demographic data and social determinants of health.
    • Implement a robust social history and PMH template into your electronic health record (EHR) to capture social determinants of health.
    • Collect demographic data for future value-based contracting and commercial payer contracting negotiations.
  • Include family history contacts and encourage new patient appointments for the entire family.
  • Share medical history and visit summary with the patient at the beginning and end of each visit to build trust and encourage continuous two-way communication.
  • Establish intentional care plans in collaboration with primary care physicians (PCPs).
    • Use a two-way referral system with automatic referral to a PCP if the patient relationship was initiated through the emergency department (ED), hospital admission or urgent care (UC). Give the patient a list of in-network PCPs to establish care, and recommended avenues to access care (when it is appropriate to go to the ED).
    • Alternately if the patient relationship was initiated from the PCP office, hardwire scheduling an appointment with a cardiologist while still at the PCP office. This allows for direct line of referral through which the patient can be added to cardiology schedule.
  • Integrate behavioral health.
    • For integrated CV programs, implement a direct link with the social work department to establish support and a coordinated care plan. Some services are billable with a licensed clinical social worker (LCSW). In a 30-physician (once private) group, we had an LCSW on staff who coordinated drug discount programs, scheduled appointments based on insurance and provided community resources to support patients in need.
  • Create education for awareness.
    • Provide specific collateral pieces on CVD (most resources are free online through AHA, Mayo Clinic, Boston Scientific, etc.)
    • Expand community reach.
      • Schedule a monthly/quarterly heart health talk.
      • Create engaging education posts for social media.
      • Connect with your local government (city council and county commissioners) on programming support (rideshare, additional aid and offerings for affordability). Most localities will jump to partner with cardiology programs. Prior experience has shown a halo growth effect with cardiology programs becoming the preferred care program for their local municipalities.
    • Use access as the foundation of your strategy.
      • Involve the care team (top-of-license approach) in caring for your most vulnerable population.
      • Bring care closer to the patient. Consider a micro clinic or shared space to bring care closer to the patient. Micro clinics could be simply adding shared hours/space for medical assistants and nurses to collect blood and vitals and perform ECGs.
      • Extend your hours. Start by designating one day a week when clinic is open till 8 p.m. Consider the social determinants and the fact that patients may have service industry jobs, making it more difficult to take time off from work for clinic visits.

Step Two: Make the Patient’s Access to Healthcare Easier to Support Health Equity

"We have, as all will agree, a free Government, where every man has a right to be equal with every other man.”

 -Abraham Lincoln

• Launch a prevention clinic.
  • Early disease detection is an evidence-based practice to improve heart health. Offer a prevention clinic that focuses on educating the community about CVD. Emphasize the importance of participation in this clinic and working with a cardiologist before disease onset for certain groups who may have a genetic predisposition to CVD or comorbidities.
• As mentioned previously, extend clinic hours for ease of access outside of normal business hours.
• Be transparent about pricing. Payments can be made in cash if patients are given prices up front and can plan accordingly. The stigma attached to healthcare costs affects an individual’s decision-making process if they think the process is daunting or the price unaffordable. Thus patients make the ED their default option for healthcare.
• Utilize resources from other organizations or create partnerships when possible – do not reinvent the wheel. Use the AHA Get With the Guidelines quality improvement and registry programs;² ACC Clinical Toolkits and numerous MedAxiom member resources that provide practices and healthcare systems with tools to identify and address variations in care. Data is available to address the care continuum from pre-hospital care through hospitalization to ensure that all patients are receiving guideline-directed treatment.
• Start slow when integrating technology – introduce remote patient monitoring.
• Encourage patients to use the free apps on their phone to monitor their vitals and activity. This data can be shared with the care team during visits.
• Suggest that patients use the EHR portal as an additional means of communication.
• Depending on the patient’s preferred communication method, consider implementing a hard-wired approach to mailing results and educational materials on a monthly schedule to optimize patient engagement.

Step Three: Your Team’s Diversity and the Community You Serve

• Assess your team’s individual diversity in the context of community that it serves. Does your team reflect the larger population or a subset of the population?
• Always focus on recruiting the right people for the right job but it would be ideal for the team to reflect the community’s constituents at every level, not just in the entry-level workforce.
• Do not assume that everyone fits into one box based on race as this won’t be the only demographic consideration when it comes to health and individualized treatment. Remember to practice personalized care with guideline-directed and evidence-based medicine that incorporate other factors such as ethnicity, gender, etc.

Step Four: Pick an Appropriate Name for Your Program or Clinic

Be thoughtful about the naming convention for your program – do not call it a ‘disparity clinic’. In our experience at one organization, the leaders had good intentions when implementing a diseased-focused population care program but chose a disparaging name for the clinic. While this was not done with ill intention, the leaders at the organization were unaware of the patients’ perception of the name and were baffled when met with underuse of the clinic and staff resistance. Be positive and thoughtful about the terms used in your communications – do not unintentionally frame it as a clinic related to burden.

Conclusion

"I've learned that making a 'living' is not the same thing as 'making a life.'"

-Maya Angelou

It’s easier for some programs to see the broader vision of this type of approach and its benefit in reducing the burden on the larger healthcare system. But for those who still question the value of reducing disparities, there’s also a return on investment at the institutional level. This approach can lead to more options for value-based reimbursement and help decrease high-cost usage (from your Eds) and length of stays in your hospital. Most importantly, these tactics can help deliver high-quality individualized care to patients and their families.

This blog was written to provoke thought and highlight opportunities for positive CV care transformation in the communities we serve. As providers, we should all make an effort to increasing evidence-based care for people of color experiencing a higher burden of CV risk factors.

References:

1. Javed Z, Maqsood MH, Yahya T, et al. Race, racism, and cardiovascular health: Applying a social determinants of health framework to racial/ethnic disparities. Circ Cardiovasc Qual Outcomes. 2022;15(1):e007917.
2. American Heart Association. Heart.org. Accessed on July 28, 2023. Available at: https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines