Health Equity: Insights on the CMS Framework and Leadership in Healthcare

As a nurse, witnessing the pervasive disparities in healthcare access was a profound wake-up call. Our conversation with Marisette Hassan takes us on a journey through the challenges and aspirations of achieving health equity, a mission that has never been more critical than in the shadow of the COVID-19 pandemic. When systems fail to serve everyone equally, the consequences are dire, and our discussion underlines the urgency of this issue. With Marisette's insights on the CMS health equity framework, we unpack the layers of this complex issue, from the importance of data collection to the necessity of culturally tailored services.

• CMS Framework
• TEP Report

With the pandemic spotlighting the stark inequities impacting Black and Brown communities, the episode with Marisette Hassan navigates the intricate paths of the CMS framework designed to bridge these alarming gaps. As we dissect the five priorities of this framework, it becomes clear that understanding and addressing the social determinants of health goes beyond mere demographics. It's a call to action for inclusive imagery, language accessibility, and a healthcare system that welcomes diversity in all forms, including provision for those with disabilities and hearing challenges. This comprehensive strategy reflects a commitment to not just heal but to include, resonating deeply with us as healthcare professionals seeking to serve all communities effectively.

Our final reflections circle back to the role of leadership in championing health equity. Sharing the excitement of developing CHAP's health equity standards, we highlight the incremental steps taken towards this monumental goal. Acknowledging Marisette's invaluable contributions, we invite our listeners to become part of a movement towards a healthcare landscape that's not only quality-driven but also equitable. Join us as we explore the nuances of health equity and take away insights that will empower you to partake in the transformation of healthcare into a system that truly caters to everyone.

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Transcript

Exploring Health Equity in Healthcare

Speaker 1 0:00

Greetings. I'm Jennifer Kennedy, the lead for quality and compliance at CHAP, and welcome to this special edition of CHAPcast, called From the CHAP Board of Directors. In this series, we're going to dive into insightful discussions guided by none other than our board's knowledge and experience. Our board brings a wealth of experience and insight and we're excited to extend that wisdom to you, the providers we serve. Their ability to communicate complex ideas and clarity has always inspired our team here at CHAP, and we're committed to showcasing thought leadership and fostering deeper engagement with our providers. Our ultimate goal is to equip our partners with insights and guidance needed to excel. So with that, I'd like to introduce what we're going to talk about today, and that is health equity.

Speaker 1 1:00

Health equity has been something that I've been learning about myself for many, many years. I have to reflect back to when I was a new nurse and I worked at Children's in DC and I was selected to be on a mother-baby project where I followed high-risk pregnant moms and then subsequently their babies for a year after, and I really got a deep dive into seeing the problems with access, particularly in urban communities, and just the inequity between people the haves and have-nots, let's say it that way and you know, there were inequities related to socioeconomic status, race, etc. So that was my first introduction, I would say, to health equity, and I feel like I've really been interested in this, and like a sponge, ever since my new nurse days. So this is going to be a great topic for me today to explore with my good friend, marisette Hassan. Explore with my good friend, marisette Hassan.

Speaker 1 2:50

She began her role as CEO and President of the Carolina Center for Hospice and End-of-Life Care in 2018. And that's where I met Marisette, when we were both steeped in the hospice space, let's say that, and, following a career in healthcare and hospice, she just took that role on with vigor and passion and served her state and her providers in the best way possible. Consultant and owner of LifeSprings Consulting, and she also serves as a vice president of community action and policy at SeaTac, and we're so lucky that she is on the board of directors at CHAP. So, hi, maricette, how are you doing today? And thank you for joining this CHAPcast.

Speaker 2 3:41

Wow, jennifer, thank you for the warm welcome and I absolutely feel like I'm the one that is fortunate being a part of the chat board. You guys are doing such amazing work in terms of everything that's happening in the field and you know, because both of us are nurses, we are absolutely about quality care and so being a part of the chat board and hearing about what's going on in home health and what's happening with hospice you know what's happening, you know in terms of home care those are things that are just dear, dear to my heart. So, so glad to be with you this afternoon. I heard you talk about your experience as a new nurse and I had a similar experience in terms of you know how, when you're in nursing school, you know you've got to go through the different rotations and, oh my God, the first baby I ever saw that was born. It just, I mean, bless me. I mean I got so emotional as a young nursing student and then went from that experience and started my career working with cancer patients, and that's where you know so often people think that patients are asleep at night.

Speaker 2 4:58

My first job was working nights on the cancer unit and I had an amazing preceptor, shirley Jeter. I will never, ever forget Shirley, and she was one of these. She was a young nurse, but she understood that we needed to set the environment for our patients. So, even though it was nighttime, patients were awake. They were not asleep, they were afraid they needed treatments in the middle of the night. We might be giving them chemo, we might be giving them blood products, we were giving them symptom management in terms of pain and anxiety meds, but we were also taking care of their room and making sure that the linens were clean and there weren't bad odors around so that they could rest comfortably.

Speaker 2 5:46

And I understood even then that it was important for me to meet my patients where they were and to be open and learn from them, as well as being able to provide care to them. But I also was learning from my patients as well. You know what were their spiritual needs, what were their family needs? So health equity has been around for a while. I think we saw that during COVID. We just sort of it expanded in terms of our awareness of the disparities, but it's always been an issue for us in terms of the care that we provide to patients and their families.

Speaker 1 6:30

Absolutely, and I'm glad you'd mentioned about the COVID-19. Epidemic, or rather pandemic. You know, this is, I think, when CMS like the bells went off. You know, there was the data there about disparity and health equity issues. It was all there, it was all there in the data and that to me was the, I guess the, the aha moment or the X factor where CMS said, oh, we need to do something formal about this and they developed the CMS health equity framework. So I guess my first question since you are my expert and I always come to you when I have health equity questions could you give our listeners that 20,000 foot update or overview of what that health equity questions? Could you give our listeners that 20,000 foot update or overview of what that health equity framework looks like?

Advancing Health Equity Through CMS Framework

Speaker 2 7:26

Yes. So I want to clarify that, although I'm working in this area, I always feel like I'm still learning and growing. Right, absolutely I'm still learning and growing, and so when I hear the word expert, I'm like is that really me in this area? I don't know, but I do want to. What I have seen in these last few years, especially during the pandemic, that we recognize that we had more people who were dying, you know, in Black and Brown communities from COVID, because of the comorbidities that we see that happen in black and brown communities.

Speaker 2 8:05

And you're right, cms has now put a framework together. There are five priorities right now and I won't take the time to dive into each one of them in detail, but the first priority that CMS has put out in terms of their framework for health equity is number one expanding collection and the reporting and the analysis of standardized data. In other words, going beyond just demographics but really looking at other pieces that surround health equity, where we're looking at the social determinants of health, where we're looking at educational status, where we are looking at drilling down into zip codes, right, so expanding the collection and the reporting. The second priority is really looking at the causes of disparities within CMS programs and addressing what those inequities look like in the policies and in the operations to close gaps. When I think about assessing causes, we know from statistics, jennifer, that and I have my hospice hat on right now that only about 35% of African American decedents utilized hospice, and so we have to sort of drill down into okay, why is it that African Americans are reluctant to use hospice? You know what are some of those reasons, and I believe that a lot of that has to do with misinformation, that there are some myths around hospice, but we've got to get to those as organizations so that we can open up access.

Speaker 2 9:45

The third priority has to do with building capacity. So when we think about building capacity, we are talking about how can I, through my organization and the workforce that I have, have a workforce that really reflects the community that I serve? And so when I think about that, oftentimes, when we look at our organizations, are our organizations really reflective of the communities that we serve? And that means that we've got to get the data on our communities and then match that up absolutely with the workforce that we currently have and not only the workforce, though, jennifer. I think we also have to build capacity when we look at hospice or we look at some of the other areas, we've got to also look at what our boards look like as well.

Speaker 1 10:35

Right Boards and leadership right.

Speaker 2 10:36

Leadership yeah.

Speaker 1 10:38

Yeah.

Speaker 2 10:39

And then there are two more priorities. So we've talked about expanding collection, assessing the cause for the disparities, building capacity, and then the fourth priority is really advancing language access. Look at health literacy and the provision of culturally tailored services. So that means that, okay, number one, when I look at our website, does the website really attract other people to it? Are we really looking at the languages that we're able to provide our brochures? Are our brochures culturally competent?

Speaker 2 11:14

I have a pet peeve, jennifer. I don't know if it's one of yours or not, but we always see the hands for hospice, right? Yes, with the butterflies and the butterflies, right. And so it's like, okay, does that really reflect what other cultures think about hospice? And then, when we look at our brochures, do we have all of our consent forms? Do we have our consent forms in a way that those that may be Latino may could understand what that looks like? Do we have pictures that reflect people from different communities? Are all the pictures just one color, right? It's like having vanilla ice cream when you want to have chocolate ice cream and you want to have strawberry ice cream. And one of my favorites, jennifer, want to have chocolate ice cream and you want to have strawberry ice cream and one of my favorites, jennifer, is pralines and cream from Baskin Robbins.

Speaker 1 12:08

I mean like we got to mix this thing up a little bit, yeah. Yeah, I think we do. You know CMS is doing their part, but you know we also have other entities in the federal government. The non-discrimination final rule just came out.

Speaker 1 12:21

And you know that's. I think if I, if I went out into you know it doesn't matter home care, hospice, whatever, would I be able to find literature in the top 15 languages? Would there be any cognizant of recognition that not only is it a federal regulation, but it's the right thing to do? Absolutely, if you're serving that area, it's to make sure you understand how people learn, how people speak, how people feel. Yes, you know, all of those things come together and I'm sorry, I didn't mean to interrupt you there.

CMS Health Equity Initiatives and Recommendations

Speaker 2 12:56

No, no no, I love it. That is definitely a piece that we have to look at. No-transcript, and so I think that is the thing that when you talk about culturally competent services and culturally tailored services, you are crafting something that is going to fit the community, based on what is going to work best for them. What is the language? And then the last thing is is really increasing all forms of accessibility. So are we providing things for people who have hearing challenges? Are we providing things for those that have intellectual disabilities? Are we looking at all those other kinds of ways that we need to increase care for those individuals as well? So CMS has put this framework together. The other thing that they've gone on to do is to also look at all of their departments. So Office of Minority Health is coming in line. They are putting everything is coming into alignment in terms of this health equity process, and so you'll see that, with Medicare and with looking at some of the ACOs and some of the things that they're wanting to do, all of this is coming in alignment, and so I believe that is going to be very important for us to do the same thing Now.

Speaker 2 14:38

One of the things that they did a couple years ago, jennifer is.

Speaker 2 14:42

They had the TEP, which is a technical expert panel for home health and hospice, for health equity, and I was privileged to serve on that particular group, thank goodness I was so excited to be a part of that. There were like 30- To have your voice in there. That's great. They were like yeah, yeah, like right, and so there were like 30 people from across the country who shared their thoughts on how we can increase access, what can organizations do, and so that's also a resource that we can give to our listeners.

Speaker 2 15:18

The report came out last year and what those recommendations look like, and CMS actually had apt associates to lead this effort, and so I know that, because they are really taking this seriously and they put together this technical expert panel, we are gonna see some changes in the regulations coming up. I know sometimes we say, well, it takes them forever to make some changes, but the fact that they've been very intentional about this every year they're asking us for more information so that we can get to the point where we can identify the root causes, we can increase access and our organizations can build the kind of capacity that's needed that's needed, right.

Speaker 1 16:05

So they formed a TEP and, as you mentioned, in not just hospice rules but in all rules that have come out over the past few years, they're asking requests for information. Rfi, yes, what do you think about this? You know, and I feel like, oh yay, you know, they're asking the questions. I know what the end game is. You're right. Regulation no-transcript.

Speaker 2 16:47

Absolutely. I think we're always about assessing the total needs of the patient and the caregiver right when we think about hospice, but I think there are these other pieces that are so important. Also, the social, health-related needs are part of this as well. When we think about housing instability, they're asking about that. They're asking about food insecurity. Housing instability they're asking about that. They're asking about food insecurity.

Speaker 2 17:17

What are our thoughts about utility challenges, transportation, and then looking at, are there other things that our hospices may be concerned about that needs to be captured, you know? For example, do we have abuse that could be happening, you know, in a home, and how are we looking at those particular things as well? I realize that it does put more on us as providers, but it gives us a clearer picture of what is actually happening in that home. And then the second part of this is that it really opens the door for our hospice providers to create partnerships in the community to get the resources that are needed, because one of the things that you know, I've heard already is well, if we assess for all of these things, what are we to do with the information? And the other piece of it is is that sometimes we get late referrals, and so what is going to be? How are we going to be held accountable for those kinds of things?

Speaker 2 18:13

You know, we get a patient that dies within 48 hours or 72 hours, and we've collected this information. Some of it is going to be common sense, don't you think, jennifer? Well, if the person died within 48 hours, you know there was no way that you were going to be able to do anything with that. But I do feel that we have these patients that have a longer length of stay, that we now, then, can partner with community-based organizations who have the resources that can help our patients and our families.

Speaker 1 18:46

Translate this to you. Know home health as well. We're waiting for the rule. The home health proposed rule is at the OMB right now, but I would expect to see you know CMS, building on what they asked last year related to health equity and additional collection of social determinants of health, because it's to me, maricette yes, hospice is important to you and me, but it's all of these things. Knowing all of these things about your patient helps you individualize the care.

Speaker 1 19:22

Because, every patient should have an optimal care experience, no matter what space they're being served, Absolutely. And how can we say we have a continuum of care if we're not looking at these things and sharing information? You know, pulling that thread through from acute to post-acute right.

Speaker 2 19:43

That's right. That's right it is that continuum is so important. I don't know if you knew this, but I did spend about three years in home health. I did not know that. I spent about three years in home health and I got I got bamboozled to do a home health because the person who hired me, she knew that I loved hospice and she said I need a strong nurse leader for my home health program. And I said I don't know. She says I can teach you home health. This was during the time when Oasis was coming out. Yes, and so I did it for three years. We grew the program Right and then I got to missing my hospice people.

Speaker 1 20:23

Oh man, I hear that I made the hop from home health care to hospice myself, so I feel like I have a foot of understanding in each of those spaces. Absolutely All right. Here's my biggest question for you what should organizations be doing right now?

Speaker 2 20:43

So I think, in preparation, we don't know when the rules are going to come out, what they're going to be looking at, but we do know that the TEP gave us some areas that they're wanting us to look at. So, number one I believe that organizations need to be doing an internal assessment. First, Look at your workforce, look at the diversity in your organization, from your board all the way to your volunteers. Look at what your hiring practices are, et cetera, and look at whether or not this is where you do the external assessment. You're looking at the communities that you serve, and how does your organization match up in terms of that cultural diversity, in terms of the staff that you hire versus the patients that you are serving? I think the second thing is really doing a deep dive in terms of the demographics and statistics of the service areas that you have. There are going to be some service areas that you have that are highly diverse in terms of black and brown patients and black and brown communities, right and so looking to see what the statistics are in terms of the death rates, looking at what the income levels are, looking at you know what kinds of, when you look at the diagnoses of different patients in different communities, what rises to the top? And then what are the ethnic backgrounds of those particular patients? So, looking to see what your service area looks like in terms of the demographics there are some public health rankings are really good to really look at that. The county health rankings can give you some good information about that. But I think we've got to do a better job of kind of understanding our communities and what is there.

Speaker 2 22:41

And then, thirdly, I think we've got to look at how do we really become culturally competent? What kind of trainings are we putting in place for our staff? And so those are the three things that I think that people should begin to look at. You know, we know that every year, we're going to do mandatory training. Well, cultural competency is something that needs to be happening all the time Looking at our implicit biases, really looking at how we create a culturally appropriate environment with the staff that we have.

Speaker 2 23:13

And that may mean what do we do to include not just diversity but a sense of belonging? That I know that. You know I'm in an organization that embraces who I am, whether it's LGBTQ+, whether I have a Latino background, whether I'm African American, whether my faith is different. You know what are the things that you're putting in place to create that the to reach out and connect with the people that are in your community, looking at what are those groups that you need to partner with, who are those community-based organizations and not leaving out the faith community members, who are influencers that you need to partner with and find out what it is that they need not just going to the communities because you want to pick up some referrals, because you want to be a part of the community and you want them to see you as a partner as well. So I would start with those things.

Speaker 1 24:26

Those are big things, and you know what A few of them I? I thought, oh my gosh, when CMS, you know, first started putting information out in these proposed and final rules a few years back, I thought organizations should take the cue right then and start doing something. But this is good. You know, it's never too late to get on the horse and get moving right. So those are all great suggestions. So I want to ask you in closing, when providers finish listening to this podcast, what's one thing that they should do?

Speaker 2 25:03

One thing that they should do. I think they should pull their senior leadership team together.

Speaker 1 25:09

And.

Strategic Leadership and Health Equity Standards

Speaker 2 25:09

I think this all starts with leadership. It's like what you guys have done. You know at CHAP that it all begins at the top, the senior leaders, that you're intentional and I think that's the first step is that where are we as an organization, with the senior leadership, and then devise a strategy. You know what is going to be our strategic plan and I always encourage people not to feel like they've got to do everything at once. You just begin one piece at a time. You know and get started, but start with that senior leadership, put a plan together and then begin to roll that plan out. It may be that that plan gets rolled out every quarter you're doing one thing, or you may be every six months being able to do something, but it starts with the senior leadership first.

Speaker 1 26:00

That's a great idea. You know, a journey starts with a single step right, so that's what we've got to do here. And you know I'm really excited that you were able to join me today and talk about these important things, but I also wanted to thank you for helping CHAP draft our health equity standards, which are coming either later this year or at the beginning of 2025.

Speaker 1 26:28

Oh yeah, I'm so excited about that, yeah the beginning of 2025, because we feel that it's really, you know, it's so important that we at least embed the basics into our standards of excellence, and you have been so insightful and so helpful with the development of these standards, so I wanted to just give you a shout out and thank you for that.

Speaker 2 26:49

Thank you, Jennifer, for including me. You know, anytime you and I can chat, I'm ready.

Speaker 1 26:56

I got you on a speed dial, Marisette.

Speaker 2 26:58

There you go.

Speaker 1 27:00

All right. Well, thanks again, Marisette, for joining us today and kicking off our special chap cast series Board of Directors, and I wanted to thank all of you for taking time out of your day to plug into this special podcast. So, from me and the entire CHAP staff, keep your quality needle surging forward, stay safe and well and thanks for all you do. Thank you.