The Impact of Trauma and Systemic Racism on Wholistic Health Equity

Abundant data on wholistic health disparities mandates intentional, sustainable quality improvement action. Will the next generation of metrics account for this reality?

There is an industry priority to right the societal wrongs associated with historical trauma and systematic racism. These long-standing realities are key drivers of wholistic health disparities: physical, behavioral, and psychosocial health.. A fluid stream of outcomes mandate concordant approaches to racial, ethnic, and other cultural contexts of treatment (e.g., disability, familial choice, gender orientation, regional influences). Yet, despite research to validate data wholistic health outcomes, reflective quality metrics have not been developed.

What Are We Talking About?

            Abundant data assesses the impact of historical, racial, and other types of trauma on health and behavioral health outcomes. Increased healthcare utilization has been identified for survivors of physical and sexual trauma, primarily minority women. Campbell et al. (2002) studied 2,355 females, 21-25 years old, enrolled in a large health maintenance organization (HMO). Patients who experienced intimate partner violence had a far higher prevalence (>50%-70%) of gynecological and central nervous system complaints (e.g., back and pelvic pain, fainting, headaches, seizures), plus other stress-related health issues (e.g., hypertension, insomnia, susceptibility to viral/bacterial infections). Purkey et al. (2020)identified trauma survivors as frequent users of primary, urgent, and emergency care for acute and chronic symptoms. Clarke et al., (2019) discussed the presence of vague somatic complaints by patients who endured traumatic experiences (e.g., ACEs, bulling, pressures to excel in school and career). Costly emergency department visits and ambulatory diagnostic tests are frequently used to identify etiology for chronic and diffuse pain, digestive problems, headaches accompanied chronic illness exacerbation, yet to no avail.    

Another vital dyad for attention involves chronic pain management and stigma experienced by patients from marginalized communities. Wallace et al. (2021) completed a recent study; participants were trauma survivors (e.g., historical, racial, sexual) and members of indigenous, LGBTQIA+, or refugee communities. The results were telling. When physical and emotional pain were expressed to providers, they was minimized or dismissed. If acknowledged by providers, short-term prescriptions were given versus referrals to behavioral health and other specialists.

What Does it Imply?

Data mandates the need for intentional, sustainable quality improvement in this arena. Will the next generation of metrics account for this reality? Racism remains a major factor to drive racial and ethnic inequities in health and mental health, though fails to be addressed in healthcare’s quality proposition. Of the articles reviewed for this blog post, trauma-informed quality analysis of care remained elusive. 2021 saw a fresh generation of industry health equity measures, yet few addressed integrated care, let alone assesses wholistic health equity. Existing metrics continue to silo health or behavioral health. Insufficient focus has been on industry-vetted quality models addressing population-focused, concordant, trauma and equity-focused interventions. 

Where Will Health Equity’s Quality Compass Point?

This author is developing a Quintile Aim for consideration, which adds the pivotal domain of Wholistic Health Equity to the industry’s seminal quality compass. NCQA continues to push this agenda in evolving new metrics. Public comment is open (until 3/11/22) for new HEDIS measures targeting the SDoH. Wyatt et al. (2016) posed a 5-step quality model for organizations to advance health equity delivery to the communities they served, addressed in Figure 1. 

Figure 1: A Framework for Healthcare Organizations to Achieve Health Equity (Wyatt et al., 2016) 

Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J (2016). Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper: Institute for Healthcare Improvement 

The model was well-intended though had limited substance or strategic action to leverage the intent. This effort was reminiscent of the Quadruple Aim; little data drove the model and obstructed full industry acceptance. By contrast, Dover and Belon’s (2019) Health Equity Measurement Framework (HEMF) is worthy of exploration. Based on the World Health Organization’s Social Determinants of Health model, HEMF vast evaluation areas to measure health equity at macro, meso, and micro levels, as shown in Figure 2. 

Figure 2: HEMF Framework Elements (Dover & Belon, 2019)

Dover, D.C. and Belon, A.P.  (2019. The health equity measurement framework: a comprehensive model to measure social inequities in health. Int J Equity Health 18,36

The HEMF model is worthy of a test drive to gauge its true merit. Use of the wide-scope of theoretical and evidence-based industry elements is an asset. Population diversity and complexity are accounted for through power-related and disparity measures. Health beliefs, behaviors, and values are acknowledged with stress factored in; the traumatic-response across circumstances is embedded. My desire to keep this post brief limits further elaboration on the HEMF model. However, know it poses strong value as a robust quality model to address health, behavioral, and racial health disparities across populations exposed to trauma’s diverse lens.  

Have other integrated care quality models that account for wholistic health equity? Add your considerations and comments below!

12 Ways to Bust Brain Fog

Brain fog has become a common occurrence across age groups. Clear strategies can ease the stress and bust those brain fog symptoms.

As colleagues and peers know, I’m in a Doctorate of Behavioral Health program. My quest for learning is insatiable, especially in a curriculum focused on integrated care, medical literacy, leadership, healthcare quality, and entrepreneurship. Amid my zest to gain knowledge, my brain and I can be at odds. This precious organ periodically reminds me it will only absorb so much information. My critical-thinking is challenged by episodes of brain fog: a collection of symptoms impacting the ability to think, such as distraction, memory lapses, word-finding, and utter frustration.

Activities that would previously take me 30 minutes, took hours. Anxiety kicked in, then rapidly escalated. I worried my brain fog was caused by a medical condition. At times, I thought it was due to being a post-menopausal women on a rigorous academic journey. Instead, I learned there was another explanation. I was among a new generation of persons dealing with the condition. Brain fog has become a common occurrence across age groups, impacting hundreds of millions of persons around the globe.

Brain Fog More Norm Than Exception

A variety of medical conditions are associated with brain fog (e.g., anemia, autoimmune disorders, COVID, diabetes, migraines, pregnancy), as well as stress. In fact, brain fog and stress are in a synergistic dance. We become easily overwhelmed by daily tasks. We struggle to remember the name of the last movie we watched, our beloved actor, favorite restaurant, or just the last thing we ate. Studies have addressed the traumatic impact of the recent waves of chronic, pandemic-related stress on populations: fear of virus transmission and personal/family safety, grief and loss, job and economic security, increased isolation, profound fatigue. Simultaneously occurring societal tensions have meant an added psychological hit for the population. 

Stress and the Brain

Prolonged stress and associated allostatic overload amplify cortisol production. This can lead to behavioral health manifestations, such as anxiety, depression, and insomnia. It can also exacerbate co-occurring chronic illnesses (e.g., asthma, cardiac issues, diabetes, lupus, multiple sclerosis). Our pre-frontal cortex is in peril, as continuous stress impacts the ability to engage in mental calisthenics necessary for normal cognition. Carry-over of new learning, concentration, focus, and memory are all at risk. We become stressed about being stressed, which sends us spiraling further. Neural plasticity falters as the brain loses its ability to rewire itself. Fear reigns as we worry brain cells are leaking out faster than they can ever regenerate! 

Take Control to Bust the Block

Managing our stress is key to busting brain fog! Here are 12 ways to bust those brain blocks:

  1. Breathe: 4,7,8 breathing is a must: breath in for 4 seconds, hold the breath for 7 seconds, then exhale for 8 seconds. It can be done anywhere, anytime, and any frequency. 4 cycles work, 3 times a day works wonders.
  2. Take a break: We can become too committed to finishing tasks at any expense, even if our brains don’t wish to cooperate. This floods our system with stress and cortisol. Even a brief break will enhance your efforts to regroup and refocus.
  3. Exercise: Physical activity increases blood flow, brain activity, and motivation.
  4. Get rest: Good sleep hygiene, promotes restful sleep, which is a priority. The Sleep Foundation has a lengthy list of easy ways to achieve this goal. 
  5. Monitor your diet: Hydrate, nourish, rinse, repeat. Also, watch caffeine and spicy-food intake, particularly late at night or close to bedtime.
  6. Engage in at least one peer interaction daily: Don’t let too much time go by without a quick text or meet-up with friends. They enhance your spirit!
  7. Monitor internet and social media use: ‘Doom-scrolling’ is an energy-drainer, so set limits on social media use!
  8. Engage in one positive activity daily: What one thing do you engage in daily that is energy replenishing versus depleting?  Cooking, gardening, meditation, journaling, taking a drive with the music blaring, or solo dance parties are all considerations.
  9. Set limits and SAY NO: Toss those tasks that stress you out. Ask for extensions of deliverables. These actions ease those pressures on you!
  10. Give yourself grace: Accept that you may not get a task done when you want: Ease the stress by taking 10, whether seconds, minutes, or hours. Give your brain permission to stop. This allows you time to regenerate, restore brain activity, and ready yourself for other cognitive conquests to come. 
  11. Be the master of one versus none: We all multi-task and simultaneously juggle activities, yet there are limits. Even the highest functioning brains hit a wall! Instead, take charge by approaching activities one by one. This relieves those internal and external pressures, while reducing your cortisol levels.
  12. Seek support: It is easy to isolate, but don’t give in! Reach out to friends and family, but also behavioral health professionals, as needed. Use employee assistance programs (EAP), organizational and community therapy resources, whether in-person or virtual. 

***This blog post is not meant to replace a medical evaluation. Scheduling an evaluation with a trusted primary care provider may be your first step!


Get going! What are you waiting for?

I’ll look forward to seeing what other suggestions you have to bust brain fog; add them in the comments space below!

Are Safety Net Programs Losing Their Safety Net?

A far bigger safety net must be in place to support these essential facilities, programs, providers, and the communities who rely on them. More must be done quickly to ensure safety net sustainability.

The nation’s 56 official safety nets strive to provide quality health and mental health to the nation’s most in need populations. Yet, new struggles to do so are endangering the lives of patients and mandate swift action.

Safety Net Realities 

A quilt of >14,000 sites comprise the safety net system: disproportionate share hospitals, federally qualified health centers (FQHCs), rural, and community health centers. Location maps and listings are accessible at HRSA’s FQHC with a safety net hospital list at their trade association website (America’s Essential Hospitals). These sites provide care:

  • Independent of patient ability to pay and immigration status
  • To the highest share of Medicaid and uninsured patients: 75% and 60% of the population respectively!
  • Across rural and urban regions and both, public and non-profit entities 

Pandemic-related financial headaches continue for the industry, safety net hospitals shouldering more than their share of this burden. Rural regions have seen a waning hospital presence, adding pressure to remaining FQHCs. The Sheps Center displays >100 closures in the past decade50% of 2020 closures for safety net facilities alone.

A recent Kaiser Family Foundation issue brief reviewed COVID’s disproportionate impact on populations covered by Medicaid and Medicare, including people of color and those who use long-term services and supports. Providers serving these patients were less likely to have received monies from the $178 B in pandemic federal provider relief funds; barely $13.1B went to safety net hospitals with a mere $11B to rural providers. This reality contributes to national health expenditures soaring to $4.1 Trillion dollars. The amount accounts for early 2020 through the pandemic’s first wave, which hit safety net facilities hard. Pandemic-related losses for the largest safety net hospitals (e.g., 1000 beds) are as high as 50% of their quarterly revenue. 

Loss of 340B Drug Discounts

Recent loss of 340B drug discounts has meant major fiscal challenges for safety-net programs. The legal battle against drug makers wages in the courts. HRSA has stepped up, imposing fines against drug makers when possible. A study of 510 urban facilities identified losses at 23% of savings from due to loss of 340B, a median of $1 M. Critical access hospitals saw 40% of savings lost, roughly $220,000. While that amount seems small, it is a major hit to these rural hospitals with a max of 25 beds, located 10 miles from other providers. While dollars and losses are relative to each organization, the bottom line is the same; patient endangerment from cuts and closures of needed programs, potentially the only facility or service provider for miles.

How to Save the Safety Nets

7 ideas are posed by experts to strengthen the safety-net foundation: 

  1. Increase federal funding: Target funds to hospitals that qualify for Medicaid disproportionate-share hospital (DSH) payments. Use hospital census data to more equitably distribute payments to facilities that primarily treat uninsured and Medicaid patients (and not Medicare patients). 
  2. Clear Guidance: Federal agencies, as the CDC should use hospital census data to more equitably distribute payments to facilities primarily treating uninsured and Medicaid patients. This action is a sound public health reimbursement strategy moving forward. 
  3. Streamline Regulation: Reduce regulatory burdens to foster reimbursement, such as ongoing expansion of telehealth and virtual requirements and reimbursement, lengthen quality reporting programs, and extend leniency with value-based purchasing programs. These will help hospitals to recover financially from pandemic-related losses.
  4. Loan Forgiveness: Expand programs that incentivize new clinicians to accept positions in safety-net programs. This action will bolster the workforce of providers who accept new Medicaid patients.
  5. Expand Coverage Options: Advance these options to limit growth of uninsured patients and uncompensated care
  6. State And Local Initiatives: Enact policies to mitigate effects of hospital closures. Keep public and surrounding healthcare systems informed so regions can best plan for, and provide necessary outreach to service shortage areas. This will also minimize service gaps, providing safer transitions of care.
  7. Community and Volunteer Efforts: Target corporate and community investing to bridge gaps in care: create grants, fundraising campaigns, horizontal mergers, to build satellite clinics, services, and programs. 

A far bigger safety net must be in place to support these essential facilities, programs, providers, and the communities who rely on them. More must be done quickly to ensure safety net sustainability.

I know there will be other suggestions, so add them in the comment area below.

#safetynet #accesstocare #bridgethosegaps #340B #funding #interprofessionalimpact #interprofessional insights 

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