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Top Prevention Highlights

Health equity evidence-based practices and top intervention techniques

Building an organizational response to disparities

  • Establish disparities reduction goal and business case to measure costs and invest in disparities-related initiatives.
  • Champion a disparities impact statement to identify priority populations and reduce health disparities.
  • Adopt a health equity framework to target at-risk populations and accelerate quality improvement efforts.

Culture of equity

  • Designate hospital leaders and stakeholders to champion equity and health disparities reduction.
  • Provide cultural competence education and unconscious/implicit bias workforce training.
  • Promote diversity, equity and inclusion strategies in leadership and governance.

Health literacy

  • Adopt enhanced National Culturally and Linguistically Appropriate Services standards and use of health literacy and cultural competence screening tools to individualize care plans.
  • Collect language preference data and develop a language access plan to provide appropriate language services.
  • Tailor lifestyle programs, education, services and care to the cultural and linguistic needs of the patient population.

Equity in patient and family engagement

  • Co-design equitable systems and policies at each level of hospital care incorporating what matters most to patients and families to improve quality of care and services.
  • Develop processes to systematically assess and respond to the diverse needs, perspectives, interests, values and beliefs of patients and families from all backgrounds.

Reducing readmissions in vulnerable populations

  • Comorbidities: focus on full spectrum of the patient’s health including effective communication, care coordination and preventive care utilization, ensuring that a robust referral structure is supported by systems to assess multifactorial risks prior to admission, during and after a hospital stay.
  • Collect data to identify at-risk groups and activate multidisciplinary teams to identify root causes, analyze demographic/risk data and redesign transition processes.
  • Use evidence-based interventions to address disparities and promote effective chronic disease prevention and treatment (i.e., screening, provider reminder/recall systems, small media, telehealth).

Community partnerships and collaboration

  • Engage community partnerships to improve healthcare utilization and align hospital strategic priorities with community health needs assessments.
  • Track and aggregate social needs data to guide community partnerships and leverage asset mapping to deploy patient-centered, community-based interventions.
  • Gather community feedback to inform cultural and linguistic appropriateness of policies, practices and services.

Data collection, stratification and use

  • Educate and train workforce to collect patient self-reported (“gold standard”) race, ethnicity and language data at multiple points of care beyond registration.
  • Prioritize standardized demographic and language data collection and use of data tools to diagnose disparities in quality of care.
  • Collect, screen and document patient social determinant data and utilize Z Codes and assessment tools to better understand, identify and address associated risk factors.
    • Integrate SDoH data into the electronic health record to target interventions for high-risk individuals.
  • Develop real-time equity dashboards and scorecard data stratified by key performance measures; disseminate to leadership, providers and community stakeholders.
  • Implement quality improvement programs and evidence-based interventions to advance health equity and improve healthcare quality throughout the organization.