Category: Case Management

Wholistic Health Equity Determinants and the LGBTQIA++ Community

Too little emphasis has historically been placed on this population’s challenges in addressing these determinants, as in accessing quality concordant health and behavioral health care, managing their psychosocial health and reflective resource needs, and activating action to mitigate their abysmal health outcomes. Systemic racism further perpetuates each of these disparities, triggers trauma that activates physical illness, while also compromising individual safety. It is time to shift this trend.

A number of this blog’s followers expected me to review the recent (May 2023) Federal Reserve Report, The Economic Well-being of US Households in 2022 this week. The report poses interesting implications about the Wholistic Health Equity Determinants discussed in my last post. While this topic is of interest to my health equity lens, a more critical focus beckons.

With PRIDE in full stride, the dire needs of the LGBTQIA++ community will receive prime attention today, and for my next several blog posts. Too little emphasis has historically been placed on this population’s challenges in addressing these determinants and continues to be the norm. The community still struggles in accessing quality concordant health and behavioral health care, managing their psychosocial health and reflective resource needs, and activating action to mitigate their abysmal health outcomes. Systemic racism further perpetuates each of these disparities. It triggers trauma that further exacerbates physical and behavioral health, while also compromising individual safety. Time to shift this trend.

Recent Realities

The recent article in Health Affairs by Auerbach & Fox nailed it: “significant evidence suggests that virtually all LGBTQ++ populations are at elevated risk of preventable illness, injury, and death.” This article and previous works by the Kaiser Family Foundation, University of Wisconsin’s Institute for Research and Poverty, and HRC arm us with considerable data to advance action!

Poverty and Food Insecurity

An increasing incidence of the LGBTQIA+ community live close to the federal poverty level:

  • 34% have incomes below 200% (of the FPL) vs. 25% of non-LGBTQIA++ people.
  • 39% earn $30,000 a year or less annually. 
    • 28% of lesbian and bisexual women compared to 21% of heterosexual women. 
    • 23% of gay and bisexual men compared to 15% of heterosexual men.
  • 32% of transgender persons earned an annual income of under $10,000 compared to 23% of heterosexual persons.
  • Lesbian couples have the highest poverty rates followed by heterosexual couples and male same sex couples.

In general, across the community:

  • 30% are unable to pay their bills.
  • 67% used all or most of their savings for healthcare expenses.
  • 52% had trouble paying medical bills in the past 12 months or had difficulty paying for necessities (e.g., food, heat, or housing) 
  • 41% borrowed money from family or friends.
  • 2x as likely to experience food insecurity than other populations at rates upwards of 30% of the population. One recent study reported female sexual minorities as: 
    • 52% more likely to experience nutrition obstacles, and
    44% more likely to report household SNAP assistance than their heterosexual counterparts. 

Unemployment

Unemployment rates loom large for the community:

  • 22% of adults vs. 16% of straight and cisgender counterparts
  • 29% of transgender adults, 30% of bisexual women

Amid the pandemic these numbers soared with surveys revealing as high as:

  • 28% of LGBTQIA+ report that they, or another member of their household experienced a job loss vs. 23% of the rest of the population, and
  • Close to 50% report their work hours reduced.
  • 45% of the population reported challenges paying their rent or mortgage vs. 32% of the remaining population.

Quality of and Access to Necessary and Concordant Care

The Kaiser Family Foundation yielded concerning results in the context of chronic illness management:

  • 47% have an ongoing health condition that requires regular monitoring, medical care, or medication.
  • 21% have a disability or chronic disease that keeps them from participating fully in work, school or housework.
  • 34% of those on Medicaid with a disability or limiting chronic disease report the following experiences with providers:
  • Not believe they were telling the truth (16% )
  • Suggest they were personally to blame for a health problem (13%)
  • Assume something about them without asking (21%)
  • Dismiss their concerns (29%)

Trauma and Chronic Illness Exacerbation

The community’s higher rates of exposure to psychosocial stressors contribute to higher rates of chronic and autoimmune illnesses. The higher incidence of individuals to poverty, unemployment, homelessness, interpersonal violence, as well as family and peer abandonment, contribute take their toll across LGBTQIA++ populations.

Research notes high incidence and prevalence reported for the onset and exacerbation of migraines, respiratory issues, HIV/STIs, diabetes, heart attacks, hypertension, arthritis, visual/hearing impairment, and stomach/gall bladder trouble, along with substance use and addiction. Neurological symptoms can be especially fierce in response to the expansive psychosocial stressors faced by individuals.

But Wait, There’s More

The pervasive WHED struggles of the community contribute to higher rates of discrimination, trauma, and, ultimately, more intense behavioral health conditions and mental illness. The incidence of suicidal ideation, gestures, and completed actions are at record levels, and for the youngest members of the LGBTQIA++ community. This topic deserves its own blog post and where I’ll go next time.

In addition, there must be defined recommendations for industry action. Reports have noted a variety of recommendations that ensure protective factors are in place for members of the community; these may include having healthcare providers and practitioners promote inclusion and belongingness, as well as expanding access to concordant treatment specialists. Emphasis has also been placed on individuals reducing isolation, leaving rural areas and residing in more urban areas, seeking higher levels of education, being employed, being married, not growing up in poverty or becoming a parent at a young age. 

These  factors make for a nice wish list but may not directly eliminate the immense disparities that have plagued the community for centuries. More can and must be done. Stay tuned for my next bi-weekly post. 

Time to Advance Wholistic Health Equity Quality

In response to this growing price tag the industry has evolved a fresh generation of quality frameworks, metrics, and models to forge a more comprehensive health equity vista. However, all of these efforts fall short of that goal. Every organization and entity still uses different metrics to measure and benchmark their actions. The actions of NCQA, the National Quality Forum, and CMS (through their Health Equity Pillar) are not for naught. Yet, there remains no viable, formal roadmap adopted to align cross-sector efforts and steer a successful course toward wholistic health equity; at least not until now. 

Whole person care is the ideal model to attain health equity across populations, though current quality metrics are not aligned to the wholistic health compass. Despite decades of research and successful outcomes, Integrated care’s domains of physical and behavioral health continue to remain remain siloed. While the social determinants of health and mental health (SDoH and MH) dramatically impact health and behavioral health outcomes across every practice setting, they are inconsistently factored into national quality models. 

What Comprise the WHEDs

Systemic racism, historical, developmental, and event traumas are also well recognized in the literature as correlates of health disparities. The Political Determinants of Health (PDoH) add their fury to the fire by fueling worsening clinical outcomes as a person’s social position decreases. Yet despite these facts, the US health system lacks a unified health equity vision that consistently includes assessment of these fundamental constructs. Add systemic racism, and the PDoH to the SDoH and SDoMH, and we gain a comprehensive lens for addressing health disparities: wholistic health equity determinants (WHED).

The WHED contribute to poor clinical outcomes and fiscal losses across each touchpoint of care though increased chronic illness severity, morbidity, mortality for every life stage. Vast differences appear across rural and urban regions. Safety-net hospitals have profoundly higher hospitalization utilization rates for length of stay, intensity of treatments, and costs, including readmission rates and associated penalties.

ACEs, historical, developmental, and other event traumas increase onset and exacerbation of chronic respiratory illnesses, diabetes, obesity, and mortality. Members of the LGBTQIA++ population are at higher risk than other groups of developing severe mental illness, and for experiencing an exacerbation or new onset of mental illness. Reasons for these disparities include the community’s chronic exposure to implicit bias, discrimination, and racism, as well as increased social isolation and exposure to interpersonal violence.

Given the realities addressed above, anything less than a vantage focused on the WHEDs is short-sighted. This limited gaze will not enhance quality of care for the rising number of vulnerable and disenfranchised populations across the globe.

Mandate for Action

National health expenditures now exceed $4.3 Trillion annually and will further rise. I can hear some of you muttering how this number is related to the pandemic only. Here’s food for thought: pre-pandemic these numbers had already topped over $3.8 Trillion related to chronic illness exacerbation and the SDoH. The incidence of these factors has only intensified and escalated from the pandemic.

In response to this growing price tag the industry has evolved a fresh generation of quality frameworks, metrics, and models to forge a more comprehensive health equity vista. However, all of these efforts fall short of that goal. Every organization and entity still uses different metrics to measure and benchmark their actions. The actions of NCQA, the National Quality Forum, and CMS (through their Health Equity Pillar) are not for naught. Yet, there remains no viable, formal roadmap adopted to align cross-sector efforts and steer a successful course toward wholistic health equity; at least not until now. 

Advancing the Wholistic Health Equity Quality Roadmap©

Imagine an 8-step color-coded roadmap that aligns with a dedicated total quality management process. This novel framework holds organizations across sectors accountable for improving care access and provision, and can be tailored to any organization. Quality data on the front-end is culled from evidence-based screening and assessment of health-related social needs, and uses diagnostic data (e.g., ICD-10CM-Z Codes). Revenue cycle management is as vital as interprofessional intervention, inter- and intra- agency collaboration, DEI priorities, then eclipsed by use of whole-person and inclusive- population health outcomes data. 

You’ve all been patiently waiting for me to unveil my Doctoral Culminating Project, and your wait is over! My Wholistic Health Equity Quality Roadmap© will be formally unveiled in distinct versions at the upcoming industry events, including:

A 2-part article series will also be published in Wolter Kluwer’s Professional Case Management Journal this Fall. 

The industry and its stakeholders are out of options! Implementation of the Wholistic Health Equity Quality Roadmap©  at a national level is a moral, ethical, and financial imperative that will ensure inclusive, quality-driven, patient-centered, and concordant interventions for all populations.

New Book Frames a Vivid Ethics Spectrum for the Interprofessional Case Management Workforce

Case managers strive to be ethical, and can recite the industry’s ethical tenets of autonomy, beneficence, fidelity, justice, and nonmaleficence by heart. Yet, too often case managers get caught in the crosshairs. Enter, Dr. Ellen Fink-Samnick with a timely resource and Amazon’s #1 best seller (Medical Ethics, Nursing Administration & Mgmt.) for all professional stakeholders: student, novice and more seasoned case managers, consultants, and those in leadership roles.

Ethics has long been viewed as not black and white, but rather varied shades of gray. However, these interesting times mandate a novel stance. Ethics now comprise a spectrum of vivid colors that reflect its fierce disruptions to practice, and for every member of the health and behavioral health workforce. Managing this intense reality is a constant struggle for all practitioners, especially those in case management. My latest book and Amazon’s #1 Best Seller in Medical Ethics offers clear guidance; enter The Ethical Case Manager: Tools and Tactics

Case management’s workforce faces many accountability challenges not experienced by other professions. First, case management is an umbrella profession comprised of varied disciplines (e.g., counseling, nursing, occupational therapy, and social work). Each discipline has a distinct code of ethics or professional conduct, as well as dedicated standards of practice. Let’s add another layer of complexity that includes the over 25 case management-related credentials for individuals (e.g., ACM, CCM, CDMS, CMGT-BCTM, CRC), those for organizations (e.g., NCQA, URAC)and their unique requirements. Of course, there are also a lion’s share of professional associations across the industry. The landscape gets even more precarious when including the hierarchy of case management roles that span community health workers, case management assistants, and community based case managers, to board-certified case managers, and those in leadership positions. 

The question beckons: Where should your ethical compass point? The range of established resources of guidance defined by each of the above entities makes the answer to this question challenging to answer. It also yields two confusing conundrums for the workforce:

  1. Defining the ethical and legal parameters for case management practice, and 
  2. Reconciling these parameters with employer policies and procedures across the industry.

Here’s where, The Ethical Case Manager: Tools and Tactics comes to the rescue. The book’s content is written for an interprofessional audience that spans the educational spectrum of degrees held by those in the field. This approach provides a context for accountability, while addressing the most complex ethical dilemmas to date. Attention is paid to workplace bullying, digital healthcare innovation, management of implicit biases, microaggressions, health equity and inclusion, plus interstate practice, and other population health situations. The pandemic’s wrath is woven within chapters where relevant. Didactic knowledge is blended with Federal and state regulations, innovative models, practice templates, and dedicated resources.

Each of the book’s 10 chapters includes real-life case scenarios and contemplation questions that allow learners to dig in and apply the content. 20 Ethical Tactics provide tangible touchpoints for learning. Every reader will reap their own reward, from students, to new or more seasoned case managers, consultants, as well as those in leadership roles.

The Ethical Case Manager’s 318 pages encompass the most vital areas for case managers:

  • Section 1: Essentials of Ethics
    • Chapter 1: Terms and Definitions
    • Chapter 2: Established Resources of Guidance
  • Chapter 3: The Value Proposition for Ethical Case Management
  • Section 2: Realities of practice
  • Chapter 4: Population-based Practice
  • Chapter 5: Diversity, Equity, Inclusion, and Justice (co-authored with Michael Garrett)
  • Chapter 6: Workplace Bullying
  • Chapter 7: Health Information Technology
  • Chapter 8: Interstate Practice
  • Section 3: Activation of Ethical Decision-making
  • Chapter 9: Enduring Models
  • Chapter 10: Case Scenarios and Direct Application
  • Epilogue

The Ethical Case Manager: Tools & Tactics will be your primary resource, whether you seek to:

  • Educate students
  • Onboard new staff
  • Benchmark ethical practice
  • Resolve ethical dilemmas
  • Guide compliance practices 
  • Ensure successful fiscal, clinical, and operational outcomes 
  • Employ ethical decision-making models
  • Leverage interprofessional teams
  • Inform individual practices

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The Ethical Case Manager: Tools and Tactics is only available on Amazon and for a special introductory price of $43.18. Pricing increase to $69.99 on 5/31/23.

Attending the upcoming Case Management Society of America Conference in Las Vegas? You will have access to 2 exciting book signing events: 

  • 6/27/23-Pre-Con, Telehealth 2024: Advancing Case Management’s Practice Proficiency, 2:15-3:15 PM
  • 6/29/23-Exhibit Hall book signing at the Case Management Institute table, 11 AM to 2:30 PM. Discounted rates, bulk orders, and bundled specials will be available! 

#ethicsmatter

#ethicalCM

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