Tag: DEI

The U.S. Playbook to Address the SDoH: Launchpad vs. Final Comprehensive Strategy

The White House released the inaugural U.S. Playbook to Address the Social Determinants of Health. The document serves as an important cross-sector guidepost for application, implementation, and action by all involved stakeholders to best serve their patients and communities. But, does the Playbook go far enough to fully address the SDoH? What other opportunities loom?

It’s been another exciting week for those of us taking our daily walk down Social Determinants of Health Lane. The White House released their U.S. Playbook to Address the Social Determinants of Health. The document has captured the industry’s attention, though also yielded some scrutiny.

The Lowdown

The Playbook is a bold undertaking. The document level-sets the massive work engaged in so far to address the health disparities and barriers to care engaged in across the industry. It quotes research and seminal reports citing the clinical and fiscal impact of health inequities faced by society’s minoritized and marginalized populations and providers. This vital foundation also highlights the importance of patient- and family- centric care that heeds the Quintuple and Quintile Aims at micro, meso, and macro levels, and across involved sectors.

For those who want the Cliff Notes version, here you go. Pages 1-18 provide critical information for persons and organizations who seek foundational information on SDoH (e.g., research, definitions, models) and context for them. This is especially valuable knowledge for students, as well as those who might not be as informed on this topic.

For my colleagues who have been in these trenches, pages 18-35 detail the three Playbook pillars with numbered strategic actions to advance each pillar. There is a candid and comprehensive review of the context for each pillar and potential challenges for implementation. Opportunities for Congressional Action are also detailed.

1. Expand data gathering and sharing: Advance data collection and interoperability among health care, public health, social care services, and other data systems to better address SDOH with federal, state, local, tribal, and territorial support.

2. Support flexible funding for social needs: Identify how flexible use of funds could align investments across sectors to finance community infrastructure, offer grants to empower communities to address HRSNs, and encourage coordinated use of resources to improve health outcomes.

3. Support backbone organizations: Support the development of community backbone organizations and other infrastructure to link health care systems to community-based organizations

The Appendics (pages 36-46) discuss how aspects of the Playbook are currently being operationalized using the Whole of Government approach. This section is a ‘must read’ for it provides specific examples to operationalize each action, with further guidance and information for readers on funding opportunities, toolkits with existing screening and assessment resources, and other critical community activities.

To Be Clear

Like most Federal reports and position papers, the Playbook was not developed as a ‘be all to end all’ document. This valuable resource highlights the mandate for all stakeholders and sectors of health and behavioral health services to ensure the most robust and sustainable approach to inclusive care for all populations possible.

How each organization accomplishes this critical priority is on them. Some might have preferred a greater Playbook focus on expanded funding and reimbursement, and that’s one clear opportunity. My take for ensuring organizational success in addressing the SDoH involves ten elements:

1. Take an honest and critical look at their current SDoH priorities.

2. Identify their target populations most impacted and develop means to ensure equitable and accessible care for all persons. This also includes incorporation of quality metrics and relevant outcomes that go beyond length of stay and readmissions to population-specific health priorities (e.g Patient-reported Outcomes Measures).

3. Align all existing inter- and intra-organizational resources and community partners.

4. Utilize and partner on funding access and opportunities; this includes ongoing investment in their communities served, advocacy for appropriate reimbursement (yup, those ICD-10-CM Z codes), and other fiscal imperatives.

5. Ensure appropriate mechanisms for data-gathering, interoperability, and use.

6. Heed industry compliance requirements (e.g., CMS, the Joint Commission, NCQA, NQF) to implement formal patient assessment (or Health-related Social Needs (HRSNs)) intervention, and direct referral linkage.

7. Ensure diverse and sufficient interprofessional staffing who can provide concordant and respectful whole-person care to all populations, which leverages integrated care frameworks and integrated behavioral health models of treatment.

8. Prioritize workforce training on trauma-informed approaches to care, eliminating implicit and explicit biases and microaggressions, and maximizing ethical engagement to enhance patient engagement and treatment adherence versus compliance and resistance.

9. Ensure the alignment and application of Diversity, Equity, Inclusion, and Belonging (DEIB) policies, whereby all patients and the industry workforce feel safe, seen, heard, and valued.

10. Commit to long-term strategic solutioning of the SDoH rather than short-term reactive response.

In Closing

“The Playbook is a launchpad, and not a final comprehensive strategy for addressing the SDoH”. It may not go as far as all stakeholders would like. Yet, the Playbook serves as an important guidepost for necessary cross-sector application, implementation, and action by all entities and individuals to best serve their patients and communities. I trust readers of this post will weigh in with other suggestions, and that input is encouraged. Just remember, final accountability for advancing these efforts is on us all.

The Case for Diversity in Health and Behavioral Health Professions is More Than Powerful: It’s an Interprofessional Mandate

The face of the current health and behavioral health workforce fails to mirror the workforce it cares for. The recent SCOTUS decision will only further negate cross-sector efforts to attract, admit, train and, sustain the inclusive workforce patients need. What must happen to mitigate this massive gap in care?

I am a fan of the Commonwealth Fund’s issue briefs, and the recent one on The Case for Diversity in Health Professions Remains Powerful was especially significant. The messaging was in direct response to the latest SCOTUS decision on Students for Fair Admissions, Inc. v. President and Fellows of Harvard College. For those who missed it, this decision removed “race-conscious affirmative action” in undergraduate admissions. This decision is poised to drop Black and Hispanic admissions by at least 10%, and strike a blow to diversity, equity, and inclusion (DEI) in education. The ripple-effect of this decision across all historically vulnerable populations was made clear in GLAAD’s post-decision statement: 

 “This decision inaccurately and unfairly limits access to the American dream, and drags our entire country backward, upending decades of precedent and progress. Equity for Black Americans and all people of color, including LGBTQ people, is essential to our democracy, economy, and future. This decision could also open the door for challenges to DEI practices in business settings and it is critical that companies and educational institutions respond with loud commitments to continue best practices for inclusion.”

Gaping wholistic health disparities already limit access to necessary physical, behavioral, and psychosocial health. The face of the current health and behavioral health workforce fails to mirror the workforce it cares for. The recent SCOTUS decision will only further negate cross-sector efforts to attract, admit, train and, sustain the inclusive workforce patients need. This action has great potential to inflict greater harm to a population already dealing with historical, experiential, developmental and other traumas. What must happen to mitigate this massive gap in care?

The Current Discordant Reality

I was educated and trained at a time when practitioners were often taught that anyone could work with anyone; I fought the opposing views for years. However, the research to support concordant care is equally compelling. I feel strongly that we must teach and emphasize the importance of cultural humility and work to eliminate implicit and explicit biases in practice. But, we also have an ethical obligation to be sensitive to the cultural nuances that come with caring for others. Every patient deserves to feel safe and a sense of belonging in the context of their care and treatment.

Academic programs across every discipline are working overtime to fill the massive void of practitioners available to treat underserved communities and their populations. Conclusive data validates how patient-provider concordance makes a difference in the quality of patient engagement, trust, and satisfaction. Patients do better in treatment when they feel that their providers and practitioners understand them and look like, and this reality transcends the cultural schema. However, current workforce demographics fails to ensure any level of concordant care.

A recent report  of medical residents yielded: 

  • Black men make up less than 3 %of all physicians
  • <1 percent identify as American Indian, Alaska Native, Native Hawaiian, or other, Pacific Islander

For active physicians:

  • Persons who identify as men comprise a majority of the physician workforce: 63% vs. 37% (women) 
  • Persons who identify as women comprise >50% of the medical specialties focused on children, women, and families (e.g., reproductive health, pediatrics, neonatal and perinatal medicine, and child and adolescent psychiatry). 
  • 64 %: White
  • 20.6 %: Asian 
  • 6.9%: Hispanic, and 5.7 %: Black or African American. 
  • Barely 1 %: multiple races and non-Hispanic
  • < .3%: American Indian or Alaska Native or
  • .1% Native Hawaiian or Other Pacific Islander

Data for mental health practitioners yield equally concerning results, particularly in light of the high demand for care. A survey >37,000 mental health professionals yielded abysmal numbers that fail to reflect the diversity of populations requiring intervention and treatment:

  • 74.2%: White  
  • 7.9%: Black or African American 
  • 7.9%: Hispanic or Latino.
  • 3.1 %: Asian
  • .7%: American Indian or Alaska Native

There are insufficient health and behavioral health professionals trained to work with the LGBTQIA++ community, and ensure patient safety, trust, and satisfaction with their care. 

Persons with Disabilities have limited representation in the healthcare workforce. A report from 2022 revealed:

  • 7.9% employed within healthcare with 4% as practitioners and 4% in healthcare support roles

The industry has miles to go toward ensuring a concordant health and behavioral health system and workforce that matches the face of the population it is entrusted to care for. How else can patients feel seen, heard, and assured of the care they deserve?

Advancing Action

I rarely post dramatic data without offering ways to mitigate the gaps in care presented. Considerable action across industry sectors is being dedicated to attaining a more diverse health and behavioral health workforce. The efforts in play comprise an exhaustive list, but a few novel ones are listed below. Add others that you may be aware of in the comments section at the end of this post.

The Standardized Test Dilemma

Systemic racism has long been attributed to standardized tests across education levels, academic programs, and professional licensure. The ASWB’s report on exam passage rates revealed large racial and ethnic disparities. How will social work ensure its professional path is not laden with the same disparities and obstacles faced by populations served by the profession itself?

The Association of Social Work Board’s (ASWB) release of their long-requested report on licensure exam passage rates has prompted industry outrage. Professional response has been fierce with calls for action by every sector, especially for social work regulatory boards across the states and territories to stop giving and requiring licensure exams.The report’s appearance forced me to pause, especially as a clinical social worker with 40 years committed to patient and professional empowerment. Add my roles as a former ASWB clinical exam item-writer, social work educator, and clinical supervisor to the mix, and know I’ve engaged in my share of reflection.

Historic challenges 

Systemic racism has long been attributed to standardized tests across education levels, academic programs, and professional licensure and credentialing entities. The National Education Association calls for more authentic means of assessment, viewing the exams as “instruments of racism and a biased system”. Ibram X. Kendi states,” The tests have failed time and again to achieve their intended purposes: measuring intelligence and predicting future academic and professional success. The tests, not the black test-takers, have been underachieving”. Students who are English Language Learners (ELL), persons with disabilities, and Black males are all identified among persons least likely to receive a passing score.

Social work is not alone in its outcry over licensure exams passage rates and the associated disparities. There are countless studies, including a recent release by the American Bar Association in May 2022. The report revealed how Whites pass the Bar exam as first-time test takers (and within two years of graduation) at higher rates than graduates from other racial and ethnic groups.  

The Ultimate Dilemma

What should happen next? Herein lies the $64 M question. Social work is a regulated profession, the primary purpose of which, is protection and safety of the public; the secondary purpose is to protect the profession. Yet, I’m confident most have met individuals who are expert test takers, but less than effective practitioners.

Is exam passage necessary? If yes, what becomes the best method to “test” that an individual has the level of didactic knowledge, critical thinking, and professional maturity required to intervene as an independent clinician? If no, are other licensure requirements alone sufficient to denote competency to practice in a state, such as graduating from an accredited school of social work, fulfilling the requisite practicum hours, completion of a requisite number of clinical (direct) and work (indirect) hours, plus a set number of supervision hours? How should the minimum standard for clinical practice be defined by state boards, considering the different requirements across them?

From a liability standpoint, standardized exams were thought to provide an objective measure of the minimum standard of practice expected for that licensure/credential, though this is not the case. Protecting patient’s from harm has been a priority of licensure, but what of practitioner harm? From an ethical standpoint, conclusive data shows standardized exams in their current form, obstruct access to (independent) licensure, especially for persons of color, certain ethnic groups, and those with disabilities, among others. Practitioner harm and trauma are direct outcomes when these individuals are unable to pass the exam; professional reputation and financial status are impacted through loss of promotions or jobs, as well as dollars spent on prep courses and repeated exam application. This action fails to ensure attainment of a diverse workforce that can provide the concordant care warranted across patient populations.

The Response

From social work’s lens, if the ASWB exam is removed, what will replace it? That premise is a central consideration. Some states, as Illinois, charted that course prior to the ASWB report; the LSW no longer requires a person take an ASWB exam. Other states are actively considering their next steps.Petitions to eliminate the ASWB and the exam are circulating and gaining momentum. Other suggestions include passing those persons who took the exam multiple times and missed passage within 10 questions. Social work strives to identify and fix systems that are broken. The licensure exam process is broken, and we are beholden to fix it.

The National Association of Social Workers (NASW) released their formal response, emphasizing concern over racial disparities and need to address the “systemic racism within the profession”. Further statements have appeared from the Social Work Hospice and Palliative Care Network, and are expected from other groups.

Whatever happens next, one action is certain; strategic, coordinated, and equitable action is mandated; too much is at stake. That action must ensure social work’s professional path is not laden with the same disparities and obstacles faced by populations served by the profession itself.