Tag: Trauma

Working Around the Words to Ensure Health Equity

Considerable time, effort, and energy is being spent on reframing word use in response to Federal mandates and their ripple-effect across the industry. Shifting words should not negate our professional commitments and obligations to the patients, their families, and the workforce. Our actions must continue to advance the Quintuple Aim and what matters most.

Much has been written lately about reframing word use in response to the latest generation of Executive Orders (EO) and other actions by the Federal Government. Yet, what happens when most of the words at issue are aligned with population health funding priorities as in accessibility, health equity, inclusion, or vulnerable populations? What happens when the words are commonly used in daily language, like advocate, expression, gender, or status? What happens when the words inform competencies for public health professions, as in cultural competence, implicit bias(es), oppression, or social justice? What happens when the words speak to evidence-based interventions that support populations across healthcare settings, such as anti-racism, cultural responsiveness, feminist, social justice, and trauma-informed? What happens when the words align with ethical codes of conduct and standards of practice for healthcare professionals whether discrimination, person-centered care, underserved, and vulnerable? What happens when shifting the words eliminates populations, persons, and their identities as in gender affirming, LGBTQIA, pronouns, Trans, or other terms. What happens when the list is ever-expanding and unpredictable? It is an understatement to say resolution is complicated. 

How many ways are there to say, equitable, accessible, and quality-driven whole person healthcare? It presents there are many ways. Of course, the mantra remains that the more things we call these drivers and influencers of poor health outcomes and the persons who experience these factors the most, the less people will know what they are. These words have specific meanings; using so many different terms can invoke unintended misunderstandings. While the explicit intent of this new macro-focus is “to help Americans lead healthier lives” there is a clear and present worry that all populations may not be included in this mix. 

Managing The Latest Information Flow

The constant attack on words is exhausting and frustrating to already weary professionals, practitioners, and providers, but most definitely patients and populations. This is an equally troublesome effort to those in higher education preparing future generations of the workforce. 

The latest funding and programming shifts have left many reeling, including the March 2025 announcement to cease funding on four critical value-based care models: Primary Care First, End Stage Renal Disease Treatment Choices, the Maryland Total Cost of Care, and highly-anticipated Making Care Primary model. These shifts will impact millions of Medicaid and Chips recipients, plus Medicare beneficiaries with complex, costly chronic illnesses and the primary care practices that care for them.

This week saw Joint Commission reframe their highly coveted Health Equity Resource Center to reflect new verbiage of, The Optimal Delivery of Care for All; yes, the familiar language of “page not found” now appears when you one goes to the original website. History of Joint Commission’s focus in the health equity space is provided with emphasis on the entity’s ability to provide individual consultations to meet the new industry framing. In addition. CMS’s Health Equity Framework has been reframed as CMS’s Framework for Healthy Communities. The five pillars have also been reframed. In edition, their Health Equity Index used for Medicare Advantage Star Ratings has been rebranded as…..wait for it….The Excellent Health Outcomes for All Reward ((EHO4all). There is concern that the coveted 1115 Waivers might be next on the chopping block; time will tell.

Valuable time is being spent daily by colleagues to review, consider, and revamp programming to stop the ongoing rise of National Health Expenditures, expected to hit $5.3 Trillion. Much of my current bandwidth is spent staying current on policy and EO interpretations, but also supporting colleagues through job losses, or their fear of potential job losses. My students are coping with a constant flurry of issues from disappearing funding for their education and work-study programs to general concerns for their chosen career trajectory. 

Here’s the Real Deal

Changing the terminology will not eliminate the wrath of health disparities and inequities experienced by historically minoritized and marginalized populations. Shifting words alone will do little to improve the poor clinical outcomes experienced by some populations more than others. Adjusting how populations are addressed will not decrease healthcare utilization or improve fiscal outcomes. Eliminating some populations from the conversation or funding will not dismiss the persons from those communities who experience worse illness morbidity and increased mortality rates. Reframing new initiatives will not identify the drivers of systemic racism, political determinants of health, and other social influencers of poor health for populations. In fact, each of these actions will further deteriorate the outputs of our current healthcare system. The US will continue its downward spiral of having the highest healthcare utilization and costs, along with the worse outcomes compared to other developed nations.

While we reconcile our fury about having to change longstanding terminology, the work to address the true priority at hand must continue. We must work to implement actionable strategies that heed our ethical obligations as healthcare professionals and providers. We must continue to advocate for ALL patients and their families so they receive access to the highest quality care available. That care must also be delivered to all in a fair and equitable way. 

Strategies to Advance the Health Equity Equation

Emphasis needs to focus on defining, measuring, and incentivizing progress to improve access to quality care. A recent article in Health Affairs Scholar, posed clear direction with examples for each element provided. I encourage all to take a deeper dive into the piece to integrated these steps within your organization or practice:

  1. Define clear measures of equitable access and tracking progress at both organizational and national levels.
  2. Develop and implement equity-focused quality measures and aligned incentives to support progress and create accountability for addressing barriers in access to care (e.g., quality metrics, outcomes data).
  3. Health care leaders should undertake efforts to measure the availability and quality of health care services for people who experience inequitable access to health care and track progress towards addressing barriers to access (e.g. dashboard).
  4. Build and leverage cross-sector partnerships that allow collaboration on investing to address shared patient and community needs.

My daily dialogues with valued colleagues are a reminder to continue prioritizing ourselves and our energy. This will fuel our focus on the critical work at hand. Here are a few of my own strategies to push through this muck!

  • Stay informed through your valued sources of intel but limit the amount of time spent viewing the information each day. While old habits have me check CMS Newsroom Posts weekly, there are other personal favorites: The Commonwealth Fund, Peterson/KFF System Tracker, Epstein Becker Green, and others.
  • Explore what actionable strategies are up your sleeve
  • Don’t silo your efforts: continue to discuss and strategize with colleagues who share your passion. Those relationships and conversations will continue to nurture and motivate your efforts.
  • Try not to get lost in the alphabet soup of verbiage! Yes, it is toxic and traumatizing and will get the best of us if we let it! Instead, focus on actions to advance past the toxic energy around us. This may mean using alternative words or language, as posed in the list provided in the Federal Grant Trigger Words Replacement Workbook (yes, many alternatives were provided by ChatGPT).
  • Stay up to date; the 4/3/25 document published by the EEOC and DOJ, What You Should Know About the Recent DEI-Related Discrimination at Work is a must read. 

In the end, it is our actions that matter most to achieving the industry’s quality north star of the Quintuple Aim: patient- and family-centric care delivered at the right time, for the right cost, delivered by those who embrace the work, and assuring equitable access for all. Shifting words should not negate professional commitments and obligations to our patients, their families, and the workforce.

The Ongoing Saga of Healthcare’s Ethical, Legal, and Regulatory Dilemmas Due to those Executive Orders

Recent Executive Orders and related actions have brought new ethical, legal, and regulatory challenges for healthcare professionals.

I traditionally avoid posting on social media about anything that might be viewed as “political”. However, my view has changed amid the latest string of Executive Orders and related actions. Each of these EOs seeks to deny the presence of certain populations, restrict equitable care access for historically marginalized and minoritized communities, as well as obstruct educational and professional pathways to career opportunities for all persons.

Colleagues have authored countless articles and blogs on the intent and reach of Executive Orders, impact on DEI efforts, and related themes. The resources are worth a deeper dive for those with interest. My focus for this article is on how the issue puts healthcare professionals directly in ethical, legal, and regulatory crosshairs, and especially my colleagues in case management.

The “Flagged Words” and Existing Regulations and Requirements

The lengthy and growing list of “flagged words” to avoid in grant requests, professional references, education, and continuing education is concerning. Most of the included terms appear in rigorous CEU-requirements for the healthcare workforce, and across more than half of the U.S: accessibility, anti-oppressive practices (implicit) bias, cultural competency and/or humility, discrimination, diversity, equity, immigration, inclusion, and social justice, to name a few. For CEU-approval, these words are required to appear in presentation and training abstracts or their learning objectives. Among other cautionary words are advocate, female, gender, political, socioeconomic, status, trauma, women, and victim.

Much of the terminology is embedded within our established resources of guidance: regulatory language for licensure practice acts, federal mandates, academic and organizational accreditation, case management and other individual exam-based certifications, ethical codes of conduct, and professional standards of practice. Examples of these include:

Licensure Renewal or Not?

Many of the terms at issue appear across professional practice acts and regulations. I’d cue my colleagues to check their current CEU-requirements for any state(s) of licensure or certification; the language is crystal clear. There are large consequences for persons unable to fulfill their renewal requirements, including fiscal costs by loss of employment. There are also potential sanctions or reprimands should one choose to abandon, refuse, or rescind care (without an alternative provided) to patients in need of emergent treatment and intervention. 

Ethical and Legal Exclusions

It is understood that not every professional shares the same belief system and mores. Yet, caveats have long been written into the established resources of guidance for religious or moral exclusions and other acknowledged beliefs that could bias or obstruct a person from rendering the acceptable standards of care delivery. All professionals are accountable to complete a safe and appropriate transfer of care to minimize the potential for patients to be put at risk of physical or emotional harm. This language, or some similar verbiage, appears across professional standards of practice and ethical codes for all disciplines and advanced specialty practices, including those for my case management colleagues.

It is also understood that some professionals reside in states where certain language has been excluded under federal law. However, our professional and ethical obligations to patients, their families, and other support systems remain paramount.

In a concerning move, the Texas Behavioral Health Executive Council voted to give preliminary approval for removal of language that requires cultural competence as a CEU-requirement for several licensed mental health professions, including counseling, marriage and family therapists, psychologists, and social workers. Prior requirements for renewal were for 24 total hours of CEUs, of which 6 were dedicated to ethics and 3 for cultural diversity or competence. The proposed revision is to “ensure competency when providing services to a distinct population, defined as a group of people who share a common attribute, trait, or defining characteristic of the licensee’s choice.” The term cultural competence has long been challenged due to its implication that every professional should be competent in every culture, which is not possible. However, other terminology has been recommended from intercultural effectiveness to cultural humility. The latter term is focused on practitioner awareness of distinct cultural nuances across populations and communities with a dedicated commitment to ongoing learning that advances their practice.

The action by Texas has prompted considerable pushback with concerns by other states on how the new rule could allow practitioners to bypass cultural diversity training about marginalized communities. This action de-emphasizes the topic’s importance to the workforce, as a critical component of providing and assuring ethical and responsible care and intervention to each person. Further actions of this type will lead to gaps in the knowledge and skills needed by the workforce to effectively engage and serve clients from diverse backgrounds, cultures, and genders. Respect for the unique experiences, beliefs, and values that distinguish populations and communities will surely be at risk.

Our Quality North Star is Under Attack

Excluding words or erasing populations does not dismiss the inequities and injustices faced by those communities. Quality-driven patient-inclusive care is an industry mandate for anyone in healthcare and its associated sectors.Colleagues have even shared how content referencing the Quintuple Aim has come under fire. This construct is the long-respected Quality North Star of our industry: population and patient-inclusive care rendered at the right time, for the right cost, by those who embrace the work, and is accessible by all persons. With National Health Expenditures slated to be at over $5.3 Trillion dollars for 2025 and hit over $7 Trillion by 2031, too much is at stake for any lesser of a quality vision.

Our Enduring Professional Obligations

Advocacy is another “forbidden word”. Yet, that word remains an enduring ethical mandate and legal obligation for all licensed and/or certified healthcare professional and disciplines. All persons deserve to feel safe, seen, heard, valued, and respected. Equally included in this mix is each practitioner, our families, as well as any friends who are patients receiving care. I have no intention of waiving these obligations or shifting my professional focus of the past 42 years.

What about you?

Tackling Workplace Bullying and Promoting Psychological Safety

October is National Workplace Bullying Awareness Month. The incidence of bullying within healthcare continues to rise, and with dangerous consequences for patients, as well as the workforce itself. Identify workplace bullying’s newest dimensions and learn how to promote your psychological safety.

October is National Bullying Awareness Month. Every year I hope for improvement in the landscape of this fierce disruptor, and especially for my colleagues within healthcare. Yet, the incidence of incivility keeps rising. The post-pandemic disruption continues with workforce shortages, attrition and retention challenges, staff burnout, and a slew of occupational hazards. What began decades ago with a few posturing practitioners and nurses who ate their young remains an interprofessional sport that every discipline plays, and nobody gets to sit out.

Psychological Safety and Workplace Bullying

Bullies take chronic hits at your psychological safety. Their goal is to make you feel inefficient, ineffective, and incapable of performing your role. They mess with your perception of whether it is safe to take interpersonal risks within your appointed role at work, such as in taking initiative to advocated for patient care and treatment. They sabotage your sense of self and thus confidence so that you may fail to follow through on critical communications with team members. Ultimately, the quality of your workplace performance is questioned along with your mental health.

Bullies are ever-present across sectors and can invade your volunteer experiences, such as roles for a professional association or other efforts. An activity you engaged in for sheer enjoyment, becomes as arduous to engage in as any professional role. Ultimately your occupational health, mental health, and safety are all compromised. Every member of healthcare’s valued interprofessional workforce is impacted:

Bullying and incivility incidence have ramped up from DEIB’s lens, and impacting:

Negative outcomes are plaguing quality improvement and risk management specialists across practice settings. Incivility by practitioners leads to medical errors >75% of the time, and resulting in death >30% of the time. The workforce is also at elevated risk of trauma, and especially suicide from repeated psychological assaults:

  • Suicidal ideation: >30% of victims (of bullying) 
  • Suicide: Victims 2X as likely to take their own life compared to those not exposed

Bullying’s Advancing Dimensions

Bullying is a consistent pattern of repeated, health-harming mistreatment of one or more members of the workforce, marked by abusive conduct that is threatening, humiliating, or intimidating. Work is delayed, sabotaged, and obstructed. These are impediments that NO professional can afford in the fast-paced industry. We’re not talking about random episodes when someone feels crispy around the edges or has a bad day, but rather a chronic and recurrent pattern of behaviors that somehow devalues others.

Gaslighting, Mobbing, and Remote Bullying, OH MY!

Bullying has morphed into assorted dimensions. Gaslighting occurs when a colleague ignites the gas by tossing out an inflammatory implication that forces you or others to question your actions or ability to do the job. The bully fans the fire by ongoing attacks; they may challenge your memory of events, such as implying that you ‘forgot’ to follow up on dialogues with a patient’s family or member of the care team. There may be comments to other colleagues about your bouts of ‘memory loss’. Imagine, being approached by staff or patient families to verify if you completed documentation that you clearly recall doing. Even you start to question the quality of your work performance, especially as your reputation and job performance are at issue. Six types of gaslighting are:

  • Countering: Challenging someone’s memory 
  • Denial: Refusal to take responsibility for actions
  • Diverting: Changing a discussion focus by questioning someone else’s credibility 
  • Stereotyping: Generalizing through negative or discriminatory views of a person’s race, ethnicity, sexuality, nationality, or other cultural nuance. 
  • Trivializing: Disregarding when someone feels minimized by what is said and devaluing the impact
  • Withholding: A bully pretends to not understand a conversation and refuses to listen to another person’s view. That person ends up doubting themself. 

Mobbing is bullying on steroids and occurs when multiple staff target one or more personnel. Almost 50% all bullying incidents involve mobbing with 54% of primary care professionals exposed to this type of incivility on at least one occasion. Perhaps, a new director of Case Management at an MCO changes the job description to require all new hires to possess case management certification; current employees must be certified by the end of that calendar year. Staff view this requirement as an undue hardship and become frustrated. The rumor mill ensues: ‘The quality of the work isn’t important, only if we can pass a test.’; ‘she doesn’t care about us.’ The mob works to discredit the boss and push her out the door. Staff may view a new colleague as not fitting in, whether because of being in a different age group, professional discipline, as well as race, ethnicity, gender, sexual orientation or other cultural nuance. As a result the staff member does not feel safe, seen, heard, or valued.

Remote bullying has risen amid the increase of virtual roles. Some 43% of employees were exposed to remote bullying experiences:

  • 50% of incidents during virtual meetings
  • 10% via email interactions, and 
  • 6% during group emails and chats. 

What YOU Can Do to Promote Psychological Safety!
Bullies are insidious and invasive in their efforts. BUT, here’s their dirty secret and biggest misstep! BULLIES target the most ethical, hard-working, and high-performing individuals in an organization. If you’ve been bullied, it means you’re more powerful than you’ve ever imagined, as you’re a threat to the bully and their ineptitude.

Tackling bullying involves strategy:

  • Intervene early: Don’t let a precedent be set and address the behavior directly
  • Don’t react to the bully: ‘Take 10’ to breathe, consider, and define an approach
  • Document each incident: Date, time, witnesses, and who you discussed it with.
  • Don’t let the bully isolate you: Keep engaged with peers and those who trust your savvy.
  • Set limits on negative behaviors you will allow: We may let small things go, but stay vigilant.
  • Don’t share lots of personal details at work: This info will be used against you
  • Take time to recharge from incidents: Mental health days or vaca help restore your resilience
  • Seek Support: Peer support and mental health support are MUSTS; one may potentially need independent legal support!
  • Put your best professional self forward: Bullies thrive on the weakness of others, so keep showing that best version of yourself  
  • Approach bullying as a work project: Being methodical keeps you in control. Assess  financial costs of staff departures related to bullying, and the ROI of psychological safety and other workforce retention strategies

Those steps and other ways to advance each above strategy live in Chapters 3 and 6 of The Ethical Case Manager: Tools and Tactics. The book’s content:

  1. Defines terms associated with workplace bullying
  2. Discusses how workplace bullying impacts physical and mental health 
  3. Aligns workplace bullying, quality of care, and patient safety 
  4. Recognizes the “Bullying Recipe” within organizations
  5. Examines how the practice culture of professional education impacts incidence
  6. Explores the incidence across the DEIB landscape 
  7. Identifies types of organizational culture that contradict workplace bullying
  8. Discusses leadership styles to impact workplace bullying in organizations
  9. Identifies legislation and professional initiatives to combat workplace bullying
  10. Explores how bullying impedes the ethical performance of case managers 
  11. Offers quality monitoring tools to address unprofessional behaviors
  12. Informs you how to calculate costs of workplace bullying for your organization 

REMEMBER

Keep Ellen’s Ethical Mantras close by:

  • We deserve respect.
  • We deserve to feel safe. 
  • We deserve not to feel trapped in a toxic workplace.
  • We deserve to have our knowledge and expertise valued.
  • We deserve to have confidence that all are accountable for their actions.
  • We deserve to be able to confront workplace bullying without fear of retribution.

October is National Bullying Awareness Month. Every year I hope for improvement in the landscape of this fierce disruptor, and especially for my colleagues within healthcare. Yet, the incidence of incivility keeps rising. The post-pandemic disruption continues with workforce shortages, attrition and retention challenges, staff burnout, and a slew of occupational hazards. What began decades ago with a few posturing practitioners and nurses who ate their young remains an interprofessional sport that every discipline plays, and nobody gets to sit out.

Psychological Safety and Workplace Bullying

Bullies take chronic hits at your psychological safety. Their goal is to make you feel inefficient, ineffective, and incapable of performing your role. They mess with your perception of whether it is safe to take interpersonal risks within your appointed role at work, such as in taking initiative to advocated for patient care and treatment. They sabotage your sense of self and thus confidence so that you may fail to follow through on critical communications with team members. Ultimately, the quality of your workplace performance is questioned along with your mental health.

Bullies are ever-present across sectors and can invade your volunteer experiences, such as roles for a professional association or other efforts. An activity you engaged in for sheer enjoyment, becomes as arduous to engage in as any professional role. Ultimately your occupational health, mental health, and safety are all compromised. Every member of healthcare’s valued interprofessional workforce is impacted:

Bullying and incivility incidence have ramped up from DEIB’s lens, and impacting:

Negative outcomes are plaguing quality improvement and risk management specialists across practice settings. Incivility by practitioners leads to medical errors >75% of the time, and resulting in death >30% of the time. The workforce is also at elevated risk of trauma, and especially suicide from repeated psychological assaults:

  • Suicidal ideation: >30% of victims (of bullying) 
  • Suicide: Victims 2X as likely to take their own life compared to those not exposed

Bullying’s Advancing Dimensions

Bullying is a consistent pattern of repeated, health-harming mistreatment of one or more members of the workforce, marked by abusive conduct that is threatening, humiliating, or intimidating. Work is delayed, sabotaged, and obstructed. These are impediments that NO professional can afford in the fast-paced industry. We’re not talking about random episodes when someone feels crispy around the edges or has a bad day, but rather a chronic and recurrent pattern of behaviors that somehow devalues others.

Gaslighting, Mobbing, and Remote Bullying, OH MY!

Bullying has morphed into assorted dimensions. Gaslighting occurs when a colleague ignites the gas by tossing out an inflammatory implication that forces you or others to question your actions or ability to do the job. The bully fans the fire by ongoing attacks; they may challenge your memory of events, such as implying that you ‘forgot’ to follow up on dialogues with a patient’s family or member of the care team. There may be comments to other colleagues about your bouts of ‘memory loss’. Imagine, being approached by staff or patient families to verify if you completed documentation that you clearly recall doing. Even you start to question the quality of your work performance, especially as your reputation and job performance are at issue. Six types of gaslighting are:

  • Countering: Challenging someone’s memory 
  • Denial: Refusal to take responsibility for actions
  • Diverting: Changing a discussion focus by questioning someone else’s credibility 
  • Stereotyping: Generalizing through negative or discriminatory views of a person’s race, ethnicity, sexuality, nationality, or other cultural nuance. 
  • Trivializing: Disregarding when someone feels minimized by what is said and devaluing the impact
  • Withholding: A bully pretends to not understand a conversation and refuses to listen to another person’s view. That person ends up doubting themself. 

Mobbing is bullying on steroids and occurs when multiple staff target one or more personnel. Almost 50% all bullying incidents involve mobbing with 54% of primary care professionals exposed to this type of incivility on at least one occasion. Perhaps, a new director of Case Management at an MCO changes the job description to require all new hires to possess case management certification; current employees must be certified by the end of that calendar year. Staff view this requirement as an undue hardship and become frustrated. The rumor mill ensues: ‘The quality of the work isn’t important, only if we can pass a test.’; ‘she doesn’t care about us.’ The mob works to discredit the boss and push her out the door. Staff may view a new colleague as not fitting in, whether because of being in a different age group, professional discipline, as well as race, ethnicity, gender, sexual orientation or other cultural nuance. As a result the staff member does not feel safe, seen, heard, or valued.

Remote bullying has risen amid the increase of virtual roles. Some 43% of employees were exposed to remote bullying experiences:

  • 50% of incidents during virtual meetings
  • 10% via email interactions, and 
  • 6% during group emails and chats. 

What YOU Can Do to Promote Psychological Safety!
Bullies are insidious and invasive in their efforts. BUT, here’s their dirty secret and biggest misstep! BULLIES target the most ethical, hard-working, and high-performing individuals in an organization. If you’ve been bullied, it means you’re more powerful than you’ve ever imagined, as you’re a threat to the bully and their ineptitude.

Tackling bullying involves strategy:

  • Intervene early: Don’t let a precedent be set and address the behavior directly
  • Don’t react to the bully: ‘Take 10’ to breathe, consider, and define an approach
  • Document each incident: Date, time, witnesses, and who you discussed it with.
  • Don’t let the bully isolate you: Keep engaged with peers and those who trust your savvy.
  • Set limits on negative behaviors you will allow: We may let small things go, but stay vigilant.
  • Don’t share lots of personal details at work: This info will be used against you
  • Take time to recharge from incidents: Mental health days or vaca help restore your resilience
  • Seek Support: Peer support and mental health support are MUSTS; one may potentially need independent legal support!
  • Put your best professional self forward: Bullies thrive on the weakness of others, so keep showing that best version of yourself  
  • Approach bullying as a work project: Being methodical keeps you in control. Assess  financial costs of staff departures related to bullying, and the ROI of psychological safety and other workforce retention strategies

Those steps and other ways to advance each above strategy live in Chapters 3 and 6 of The Ethical Case Manager: Tools and Tactics. The book’s content:

  1. Defines terms associated with workplace bullying
  2. Discusses how workplace bullying impacts physical and mental health 
  3. Aligns workplace bullying, quality of care, and patient safety 
  4. Recognizes the “Bullying Recipe” within organizations
  5. Examines how the practice culture of professional education impacts incidence
  6. Explores the incidence across the DEIB landscape 
  7. Identifies types of organizational culture that contradict workplace bullying
  8. Discusses leadership styles to impact workplace bullying in organizations
  9. Identifies legislation and professional initiatives to combat workplace bullying
  10. Explores how bullying impedes the ethical performance of case managers 
  11. Offers quality monitoring tools to address unprofessional behaviors
  12. Informs you how to calculate costs of workplace bullying for your organization 

REMEMBER

Keep Ellen’s Ethical Mantras close by:

  • We deserve respect.
  • We deserve to feel safe. 
  • We deserve not to feel trapped in a toxic workplace.
  • We deserve to have our knowledge and expertise valued.
  • We deserve to have confidence that all are accountable for their actions.
  • We deserve to be able to confront workplace bullying without fear of retribution.

Medical Gaslighting and Employing Ethical Equity Advocacy

Medical Gaslighting intersects directly with health equity and is among the industry’s top priorities. What started with Lyme disease, chronic illness and chronic fatigue syndrome, now spans every disease state. There are massive fiscal, clinical, and human consequences from delayed and incorrect treatment.

Stop and consider if you, a family member, or someone you care about has experienced any of the following:

  • Had pain, or the severity of that pain, devalued by a provider?
  • Had a healthcare symptom, or severity of a symptom, dismissed by a provider?
  • Had a healthcare symptom, or severity of a symptom, attributed to “too much stress or balancing too many priorities”?
  • Had the presence, or severity of a behavioral health symptom (depression, anxiety, agitation, worry, insomnia), minimized by a provider?
  • Been told that you’re overthinking symptoms because of being “in the biz”?
  • Been interrupted by a provider while presenting symptoms
  • Had a diagnosis and/or treatment delayed or deferred?
  • Been told to stop self-diagnosing on the internet, OR
  • Left a provider feeling that you weren’t safe, seen, heard, or valued?

If you’ve acknowledged any experience on this list, then Medical Gaslighting (MG) has gained unwelcome entry into your world. What started with Lyme disease, chronic illness and chronic fatigue syndrome, now spans every disease state. However, it is also evident that MG intersects directly with health equity, and is among the industry’s top priorities.

Definitions and Distinctions

Gaslighting involves psychological manipulation through inappropriate use of power and has long been associated with bullying. Consider the boss who invalidates an employee’s thoughts, feelings, or emotions by making that person question what was said, thought, or if any of the events that were experienced really happened. Logical rationale is questioned, as well as the individual’s mental sanity. MG is an extension of this behavior and counter to patient-inclusive and proactive care.

MG is not simply a difference of opinion or negative interaction with a practitioner. It involves physician (or practitioner) ignorance and a blatant misuse of power to disregard, dismissal, degrade, and devalue the patient, their family, or other decision-makers. These actions may occur verbally or non-verbally, as in the curt reply to a question posed, eye-rolling or grimacing. Patients may face chronic interruptions by the provider and not be permitted to present their symptoms fully. Worries about increased shortness of breath, chest pain, decreased endurance, or brain fog become trivialized and chalked up to stress. Concerns about decreased mobility or functionality are automatically associated with menopause or “normal” aging.

There may be documentation entered in a person’s electronic health record noting biased perspectives of a patient’s “chronic” or “repeated” visits to the provider, or even “drug-seeking” behaviors. Perhaps a patient’s unanswered questions about their health status prompt frustration and, thus, a more assertive presentation. The provider views this behavior as aggressive and documents it as such. Patients are made to feel powerless and guilty for their self-advocacy, and blamed for being engaged and motivated participants in their healthcare process. These dynamics can easily trigger a patient’s trauma experiences, and from any point in their lives.

Ethics, Evidence, and Equity Impact

MG involves the privilege of biomedical expertise over lived experience. The physician is often viewed as a revered spokesperson for the institution of medicine; this perspective provides them with an endowed power to pronounce which symptoms are real and which are not. The result is a refusal to listen to patients and appropriately diagnose their illness, with increased morbidity and mortality rates. There are massive fiscal, clinical, and human consequences from grossly delayed, poor, and incorrect treatment.

MG is counter to the ethical principles shared by all health professionals: autonomy, beneficence, fidelity, justice, and nonmaleficence. The evidence demonstrates the concerning escalation of MG’s ethical equity impact across populations, and specific to patient physical and psychological harm:

  • 94% of patients note at least one experience of MG in their interactions with providers, with roughly 10% on multiple occasions
  • Women and Persons of Color have the highest rates of maternal mortality with dismissal of symptoms or voiced concerns, and delay in treatment; this is often associated with systemic racism and bias by providers.
    • Black women die at a rate of 41.7%, American Indian and Alaska Native women at a rate of 28.3%, and White women at a rate of 13.4%.
  • 66% of women are told (by providers) that their physical symptoms (e.g., headaches, shortness of breath, severe pain, excessive bleeding) were stress-related, or due to obesity
  • Women are 4X more likely than men to have their physical symptoms attributed anxiety, depression, or stress.
  • Diagnoses of cancer, heart disease, and other chronic illnesses in Women are often delayed by a minimum of 4 years compared to men.

Marginalized and minoritized populations experience a far higher incidence and prevalence of MG compared to other populations. Recent research validates how >50% of healthcare workers identified providers as more accepting of White patients who advocate for themselves than Persons of Color. Even when communicating the same messaging and in the same way (e.g., in-person), Whites are viewed as assertive while Persons of Color are more often assessed to be aggressive, and an immediate safety threat.

Data across these populations would fill several articles, but chew on these outcomes for now:

The LGBTQIA+ Community:

  • 50% are more likely to have experienced MG vs. cisgender, heterosexual people.
  • 40% had at least one negative experience or form of mistreatment from a health care provider in the past year

Individuals seeking Reproductive Health:

  • 72% experienced MG by providers
  • 57% were told their infertility was due to stress or anxiety
  • 54% were told that gaining or losing weight would improve their fertility outcomes
  • 37% of Women of Color were denied care for symptoms associated with cancers, blood clots, and other acute health issues.

Older Adults

  • 45% felt their symptoms were dismissed or devalued by providers
  • 54% were Women of Color

Ableism

There is a large data gap involving Ableism and MG. Ableism is the marginalization of disabled people according to their disability status. Individuals with visible and invisible disabilities are among the largest marginalized groups in the US. They face gross health inequities with poor outcomes and were officially designated by the National Institute on Minority Health and Health Disparities (NIMHD) as a health disparity population. Considerable literature speaks to the mandate for practitioner training, as well as ongoing care gaps, stigma, and discrimination faced by individuals. Yet, despite these realities and almost 25 years since passage of the 1990 Americans with Disabilities Act, systemic barriers to healthcare access are the norm versus the exception. While volumes of anecdotal data demonstrate the severity of these issues, frequent invalidation by practitioners remains a mandated area of focus for the research.

Long COVID

  • 79% report negative interactions with providers
  • 34% had symptoms dismissed
  • 39% identified delays in treatment
    • 75% identified as Female
    • 22% identified as Male
    • 3% as other

Employing Ethical Equity Advocacy

Four critical steps will enhance effective management of MG by case managers and other health professionals.

First, Heed Established the Resources of Guidance: These evidence-based and industry-vetted resources guide how professionals step into their work. These resources span professional regulations and practice acts across all disciplines, organizational accreditations (e.g., CMS, NCQA, URAC, NQF, Joint Commission) and codes of ethics and professional conduct for individual certifications and credentials, as well as standards of practice for professional associations. My colleagues in case management should be particularly familiar with their professional codes of conduct (2023) through CCMC, CDMS, and CRCC and CMSA‘s Standards of Practice for Case Management (2022). All:

  • Prioritize cultural humility and awareness
  • Mandate a whole person assessment
  • Promote health equity through every effort
  • Heed integrity, worth of the person, and objectivity in all relationships
  • Leverage ethical principles of autonomy, fidelity, beneficence, justice, and nonmalfeasance through every professional intervention and interaction.

Second, Promote Psychological Safety Using Trauma-Informed Care and Other Anti-Oppressive Practices: Implement use of Trauma-informed Care to set a space where patients, their families, and staff feel respected by, comfortable with, and confident of the care they receive, and by every member of the workforce. Every professional interaction should assure:

  • Physical, psychological, and emotional safety
  • Trust
  • Choice
  • Collaboration
  • Empowerment

This action involves more than simply offering annual and mandatory employee continuing education on the topic, or other related content on microaggressions or implicit biases. Instead, professionals should always ask:

  • Does the person fully understand your role?
  • What are their provider preferences or choices?
  • What name or pronouns they wish you to use?
  • What types of accommodations might they need with respect to physical, cognitive, intellectual, or other disabilities?
  • How will health literacy be assessed and addressed?
  • Will information be provided in the patient’s primary language, whether written or electronic?
  • Who does the patient want with them during the interview, assessment, examination, or test (if anyone)?
  • Do they know how to use, update, or troubleshoot their digital device, specific EHR platforms, or apps?
  • How do they understand their diagnosis?

Third, Employ Advocacy at the Macro, Meso, Micro Levels Practice: This domain spans policy, community/organizational, and population-based practices, such as:

  • Advance professional state-specific CEU requirements for licensure renewal encompassing Anti-oppressive practices, trauma-informed care, intercultural effectiveness, bias management, microaggressions and other related themes.
  • Advance and enforce Federal requirements by HHS, the Office for Civil Rights (OCR) and EEOC including the 2024 HHS Rights of Conscience Bill , EEOC Workplace Guidance to Prevent Harassment, and the HHS Health Equity Action Plan.
  • Case managers can also refer to the work of CMSA’s DEIB Committee for guidance inclusive of the association’s Position Statement (2024) and upcoming resources to guide case management practice. These items will encompass a dedicated standard of practice, position paper, member library, and other deliverables.

Within organizations:

  • Provide easy ways for patients and staff to anonymously report situations involving racism or discrimination 
  • Examine policies to make sure they result in equitable outcomes
  • Require coursework on bias and discrimination at professional schools, and 
  • Ongoing performance metrics that address continuing education
  • Ensure policies and procedures through Human Resources that enforce anti-discrimination practices, and are addressed through employee performance appraisals. Incentives and disincentives for heeding (or not heeding) these policies should also be consistently enforced.
  • Have patient voices reflected through involvement on boards and organizational committees and with the ability to vote on decisions.

Fourth and most importantly, Model and Mentor: Maneuvering MG is not a “one and done” activity, especially amid the changing face of patient and workforce demographics. Nobody is an expert in this space. Any ethical, caring, quality-driven professional should be committed to eliminating MG. We must recognize the uniqueness of each patient experience, and:

  • Be a steward of inclusive, empathic care and lead by example
  • Be humble and accept the need for lifelong learning
  • Strive to engage and establish rapport that fosters partnership with patients and their families
  • Talk to, and with patients and their families, rather than at them
  • Use shared-decision making for every dialogue with patients and their families
  • Inform patients of your process the start of each interaction; this will promote your valuing of their voice
  • Hire diverse staff to ensure patient populations are reflected

I know there are other strategies to stop MG and welcome those through your comments. Experience my CMSA Annual Conference presentation on MG through the digital content. Register for CMSA of Houston’s Annual Conference on 9/14 where I’ll be presenting on Medical Gaslighting’s Universal Truth and moderating a panel discussion on this topic of critical workforce importance.

Mental Health of LGBTQ+ Youth and The Trevor Project’s 6th National Survey 

The Trevor Project’s 6th National Survey on Mental Health of LGTBQ+ Young People is a must read for all health and behavioral health professionals. The mandate is clear: sustainable programming and intervention must be developed and expanded to ensure psychologically safe and concordant care is readily accessible for all youth who want it, as well as for their family members, and other allies.

The Trevor Project recently published its  6th National Survey on the Mental Health of LGBTQ+ Young People. The annual report is a must read at any point in time, and particularly for those engaged in the health and well-being of pediatric patients and their families. However, it holds special significance during Mental Health Awareness Month. In the spirit of patient-inclusive care, every person deserves to feel safe, seen, heard, and valued.

The experiences of over 18,000 LGBTQ+ young people (ages 13 -24) across the US are detailed in this seminal report. There is one big disclaimer: caring human beings will be overwhelmed by the current level of mental health risk for youth who identify within this community. 

Key Themes

This year’s report reflects several key themes, including profound levels of trauma, victimization, and a disproportionately high risk of suicide for those surveyed. It is challenging enough for youth to acknowledge and present their authentic self to others, let alone identify as part of the LGBTQIA++ community. The intersectionality of minoritized and vulnerable identities (e.g., racial, ethnic, socioeconomic, ableist) easily prompts discrimination and oppression. The layering of these marginalities only exacerbates a person’s exclusion from social connection, resources, and opportunities to engage in mainstream society; fear of stigma, rejection, and abandonment by family, peers, teachers, and other individuals is a reality for far too many individuals.

A high volume of LGBTQIA+ youth are unable to access the mental health care they need, and when they need it most. The widening gaps in treatment accessibility and availability trouble me greatly. I had a strong visceral reaction to this data during my initial read, especially as a fierce ally of the community, a behavioral health professional, and one who cares deeply about the human condition. Preliminary conversations with colleagues and friends yielded equally powerful reactions. Here are the data high points for your own reflection and consideration:

Access to care:

  • 84% of all respondents wanted mental health care
  • 50% were unable to access it

For youth who wanted mental health intervention but were unable to access it: 

  • 42%: Scared to discuss their mental health concerns with others
  • 40%: Unable to afford it
  • 37%: Unable to obtain parental or caregiver’s permission
  • 34%: Worried they would not be taken seriously
  • 31%: Fearful of being hospitalized involuntarily
  • 24%: Not yet out and worried being outed 
  • 22%: Concerned that treatment providers would not understand their sexual orientation or gender identity
  • 20%: Had a prior negative experience with a clinician

Suicidality:

  • 46% of ages 13-17 considered suicide in the past year, while 16% attempted.
  • 33% of ages 18-24 considered suicide, while 8 % attempted

For all youth who considered suicide:

  • 52%: Transgender Men
  • 47%: Transgender Women
  • 43%: Nonbinary/Genderqueer
  • 42%: Questioning
  • 31%: Cisgender Women
  • 27%: Cisgender Men

LGBTQ+ Youth of Color reported increased suicidal attempts vs. Whites:

  • 24% :Native American/Indigenous youth
  • 16%: Multiracial youth
  • 14%: Black/African American youth
  • 14%: Middle Eastern/North African youth
  • 13%: Hispanic/Latinx youth
  • 10%: Asian American/Pacific Islander youth

Mental Health and Well-being:

  • 90%: Well-being was negatively impacted by recent politics.
  • 45% of transgender/nonbinary young people: Reported their family considered moving to a different state due to anti-LGBTQ+-related politics and laws.
  • 49%: Experienced bullying in the past year
    • Those who reported being bullied had significantly higher rates of attempting suicide in the past year vs. those who did not experience bullying.


Gender-affirming treatment

  • 62% of youth on Gender-affirming hormones were concerned they would lose access to this care.

Bullying and At Risk of Physical Harm

  • 23%: Were physically threatened or harmed due to sexual orientation or gender identity
  • 28% of transgender and nonbinary young people: Were physically threatened or harmed in the past year due to their gender identity

The concerns intensify when this data point is broken down by sexual orientation, racial, and ethnic status. Prevalence increases by up to 20% when looking at gender identity by group:

  • 40%: Asian Americans
  • 36%: Blacks
  • 44%: Latinx
  • 43%: Middle Eastern
  • 55%: Native American
  • 48%: Whites

Ten Actions for Peers and Allies to Show Support

The Trevor Project identifies how to support youth, including through providing psychological safety and a sense of belonging by : 

  • Ensuring availability of gender-affirming spaces 
  • Providing access to gender-affirming clothing, gender-neutral bathrooms at school, and respect of pronouns by those they live with 
  • Having at least one adult in their school or academic setting who is supportive and affirming of their authentic self
  • Have an affirming space at home, school, work, place or worship, community, and/or social media (online)

In addition, respondents were queried on their 10 top priorities for how peers and allies can actively convey support:

  1. Trust the person knows who they are (88%)
  2. Stand up for the person (81%)
  3. Not support politicians who advocate for anti-LGBTQIA+ legislation (77%)
  4. Look up things about LGBTQ+ identities on their own to better understand (62%)
  5. Respect pronouns (59%)
  6. Show support for how the person expresses their gender (57%)
  7. Ask questions about LGBTQ+ identities to better understand (56%)
  8. Accept their partner (55%)
  9. Show support on social media (44%)
  10. Have or display pride flags (43%)

Resources to support LGBTQIA+ Youth

Prior blogs have addressed these valued resources: 

  • GLADD provides a clearinghouse of population-specific resources for advocacy, legal, and other general information. 
  • The Human Rights Campaign  advocates and promotes equity for all persons within the movement. Their massive resource database empowers allies and other community stakeholders how to support individuals with coming out, maneuvering college, elections, hate crimes, health and aging, parenting, religion and faith, and workplace support. 
  • Outcare Health offers concordant care directories with a 50-state community resource directory for LGBTQIA++ affirming practitioners, primary care, mental health, youth groups, shelters, support groups, and STI testing. They also provide an interactive map on U.S. legislation targeting LGBTQIA++ rights across the states.
  • SMYAL offers locale-based housing programs that ensure safe, LGBTQ-affirming support through tiered residential options: transitional housing, extended transitional housing, and rapid re-housing. 
  • The Trevor Project provides 24/7 information, support, and resource connection for LGBTQIA++ Youth around the globe. There is immediate access to trained counselors via call, text, or chat, and linkage to an international community for LGBTQ young people
  • LGBTQ+ Healthcare Directory provides a listing of LGBTQ+ informed and welcoming health, mental health and other providers and practitioners across the U.S. and Canada.

Readers of this blog are encouraged to add resources in the comments area below.

Data Must Yield Actionable Solutions

I echo the sentiment of my colleagues in that the industry has substantial data to validate the severity of this mental health crisis. Actionable and sustainable programming and intervention must be developed and expanded to ensure psychologically safe and concordant care is readily accessible for all youth who want it, as well as for their family members, and other allies. The risks and consequences for youth unable to access needed mental health support and intervention are far too great to ignore.

Women’s Health and Health Equity Continue Under Attack

March may be Women’s History month, but the recent events in Alabama were not any cause for celebration. They represented an attack on women’s and reproductive health and a major setback for inclusive and quality-driven patient-centered care. The need for ongoing advocacy is a must.

March is a month for celebration for it prompts attention to priorities for health equity warriors everywhere, from Developmental Disabilities Awareness Month and Social Work Month, to Women’s History Month.

This blog’s health equity happenings focus on actions that signify, yet, another dichotomy in our space this week. The events are as profound as when the Federal Health Equity Plan advanced the same week as glaring data on patient discrimination by the workforce hit the media.

In the same week that First Lady Jill Biden and the White House announced $100 M in federal funding for women’s health research and development, the Alabama Supreme Court overstepped, and (falsely) ruled that embryos are children, freezing all access to fertility treatment for women in that state. This action is an attack on women’s and reproductive health for all persons. It equally represents a major setback to attainment of inclusive and quality patient-centered care.

To Catch Everyone Up

For those who need a quick review, The Hill’s Martha Nolan wrote a stellar piece providing the realities and moving parts of In Vitro Fertilization; I’m all about attributions so give that piece a read here. However, this quote really got me thinking:

“Whatever your political or religious beliefs, limiting access to safe, effective and essential medical care is bad for women…….Alabama has made a hard situation — infertility and the struggle to have children — more complicated, stressful and difficult.”

Pregnancy is emotionally and physically stressful and traumatic for individuals. Some persons face even greater risks in walking down this road than others. Nolan frames high maternal mortality rates, which have been areas of major focus. I’m a fan of other notable data cited by the OECD and WHO, and in a wonderful article by Njoku et al. (2023). The data points speak to the profound risks faced by persons who become pregnant, whether that pregnancy is planned or not:

  • The mortality rate in the US was 32.9 maternal deaths per 100,000 live births, and >10X the estimated rates of comparable developed high income countries
  • Black and Hispanic women experience 2 to 3X higher mortality rates compared to White women.
  • Every day in 2020, almost 800 women died from preventable causes related to pregnancy and childbirth, with a maternal death occurring every 2 minutes.
  • Almost 95% of all maternal deaths occurred in low and lower middle-income countries in 2020.

These dire outcomes are exacerbated by the pervasive incidence of racial trauma, discrimination, and marginalization. The recent attacks on rights associated with the health and well-being of all persons makes this latest assault even more worrisome. Alabama and other states have made challenging situations for patients far more complicated and traumatic, from managing unwanted pregnancies (such and those during child abuse, domestic and sexual abuse/assault) and access to receiving necessary emergent medical care that saves the life of the mother. Receipt of gender-affirming care has put countless youth at risk. The latest game of political football involves management of infertility and an individual’s challenge to become pregnant. Political scrutiny dictates who defines care plan versus the rightful purview of these decisions: between patients and their chosen practitioners and specialists. The ethical principals of practice are put to test: autonomy, beneficence, fidelity, justice, and nonmaleficence.

Advocacy for Action

Yes, there is much work to do. I couldn’t agree with Ms. Nolan more in that the Biden-Harris Administration should invest in research to advance health for ALL persons. It’s tough to write a piece on women’s and reproductive health without providing attention to all marginalized groups who struggle with accessing care reflective of their needs, such as members of the Trans community. You don’t want to miss the Fierce article on how Trans men struggle for inclusive gynecological care. The topic is a relevant thread of this post given my mantra on ensuring that all patients and their families feel safe, seen, heard, and valued.

I’ll quote the White House Proclamation for Women’s History Month 2024…., though also add a respectful mandate. I understand the imperative to speak to all “women” but feel compelled to remind everyone that the rights of all identities are at stake. To that end I’ve added language in parentheses.

“All of us stand on the shoulders of these sung and unsung trailblazers — from the women (and all persons) who took a stand as suffragists, abolitionists, and labor leaders to pioneering scientists and engineers, groundbreaking artists, proud public servants, and brave members of our Armed Forces.

  Despite the progress that these visionaries have achieved, there is more work ahead to knock down the barriers that stand in the way of women and girls (and all individuals) realizing their full potential — in a country founded on freedom and equality, nothing is more fundamental.”

Far more work is needed to right the wrongs and shift the latest tide of attacks on personal civil rights. The acknowledgment of monthly designated celebrations is nice, but insufficient for the level of advocacy needed. Advocacy for action is vital. Time to get the word out to vote, plus engage in public policy actions with professional organizations, and other advocacy groups. Feel free to add to the list below.

  1. The American Civil Liberties Union (ACLU) has links to a range of reproductive freedom sites.
  2. The American Medical Women’s Association provides a further robust list of groups focused on women’s and reproductive health advocacy
  3. The American College of Obstetrics and Gynecology provides a position statement on healthcare for Transgender and Gender Diverse Individuals.
  4. The Transgender Law Center is the largest Trans-led organization focused on empowerment for the Trans community.

Federal HHS Equity Action Plan Advances Amid New Data on Discrimination by the Health Care Workforce

There’s much to follow on the current health equity radar, from advancement of the HHS’s Equity Action Plan to concerning data validating the high incidence of discrimination by the health workforce toward patients. The onset of stress and vicarious trauma for staff witnessing these events was also identified. Each of these actions will provide pause to even the most seasoned health equity warrior.

The title of this blog article reflects one jam-packed week in our health equity space! There’s much to follow on the health equity radar, from advancement of the Federal Equity Action Plan to concerning data validating the high incidence of discrimination by the health workforce toward patients. The onset of stress and vicarious trauma for staff witnessing these events was also identified. Each of these actions will provide pause to even the most seasoned health equity warrior.

An Equity Action Plan Amplified

The U.S. Department of Health and Human Services (HHS) released a 2023 update to its Federal Equity Action Plan! The plan amplified the commitment of the Biden-Harris Administration to employ its whole-of-government equity agenda that empowers inclusive access to care for all. Many of this blog’s readership are aware of my affinity for wholistic health approaches that encompass physical, behavioral and psychosocial health. Research affirms the validity of these models to ensure successful outcomes for those populations living amid the wholistic health determinants encompassing social determinants of health and mental health, political determinants health, and the systemic racism that perpetuates them.

The HHS Plan outlines five key areas to advance health equity at the macro, meso, and micro practice levels:

  1. Prevent neglect and improve care to help children thrive in their families and communities. 
  2. Promote accessible and welcoming health care for all. 
  3. Improve maternal health outcomes for rural, racial, and ethnic minority communities. 
  4. Prioritize the behavioral health of underserved populations. 
  5. Increase clinical research and trial diversity to support innovation. 

Each of these actions has been the focus of legislation and funding targeting minoritized and marginalized communities. At the Federal level Aligning for Health is a membership association that uses a team of federal and state administration experts to address the mandate for efficient, integrated and coordinated programs that enhance health outcomes for Americans. Their website has an in-time and interactive tracking tool for legislation on health equity and the SDoH. The current 118th Congress is reviewing the following legislation in this space. The current bill count tally is:

  • SDoH Bills; 118
  • Health Equity/Disparity Bills: 36 
  • Maternal and Infant Bills: 0

Since the Equity Action Plan was released in 2022, some progress to address health equity and racial justice has advanced:

  • Proposed rules on language access in all health programs and activities funded by HHS and guidance to states on how to comply with language access and effective communication obligations during and after public health emergencies. 
  • Approved 42 states, DC, and the Virgin Islands to provide 12 months of continuous postpartum coverage through the Centers for Medicare and Medicaid Services (CMS) so that women with low-incomes have stability in coverage.
  • Proposed rules that prohibit discrimination on the basis of disability by updating critical provisions that help persons with disabilities access health and human services under section 504 of the Rehabilitation Act of 1973.
  • Provided practical guidance to HHS offices on identifying actions to ensure opportunity for all.

In addition, The Kaiser Family Foundation (KFF) Medicaid Waiver Tracker shows 63 approved and 37 pending 1115 Waivers in process across the states. For those who haven’t accessed this informative tool, it is a must read. You can also access a current view of the 1115 Waiver landscape by state through the KFF Tracker.

Discrimination by the Workforce: More Norm Than Exception

This action by HHS is especially timely in light of this week’s compelling and concerning research by the Commonwealth Fund on Health Care Workers Observations of Discrimination Against Patients. The report details the perspectives of >3000 members of the interprofessional care team. Discrimination against patients due to race, ethnicity, language and other cultural areas remains widespread, as does the traumatic impact for the workforce itself. Among the most concerning findings include:

Recommendations

Much more work is required to attain the pinnacle of health equity excellence that society deserves. The Commonwealth report lists a series of recommendations to advance actions to mitigate discrimination and ensure psychological and physical safety for patients and the workforce itself:

  • Provide an easy way for patients and health care staff to anonymously report situations involving racism or discrimination. 
  • Examine policies to make sure they result in equitable outcomes
  • Require classes on discrimination at professional schools
  • Create opportunities to listen to patients of color and health care professionals of color
  • Examine treatment of non-English-speaking patients
  • Train health care staff to spot discrimination

I would also add the importance of an ongoing and consistent organizational total quality management approach. This action ensures continuous improvement efforts that are ongoing and sustainable. Addressing health equity, systemic racism, and trauma are NOT one and done.

Professional associations also need to continue their important work to develop advance, and activate strategic health equity deliverables such as implementing revised standards of practice, ethical codes, formal position papers, dedicated tool kits to name a few. 

As I’ve quoted through my health equity and DEIB work on many occasions, “Every patient, their family member, and member of the healthcare workforce should feel safe, seen, heard, and valued.”. The healthcare industry cannot possibly begin to address the health equity equation’s abysmal outcomes without first addressing these levels of oppression, racism, and manifesting trauma faced by for all involved. 

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.

Patient Compliance vs. Adherence: Advancing the Health Equity Mandate

Use of the term “compliance” instead of “adherence” by healthcare regulatory entities and organizations, plus practitioners, health systems and their and employees condones the blaming of patients for poor outcomes. It’s time to change this practice!

First, big thanks to all who read my last blog post Health Equity and the SDoH are Not Synonyms. That article has quickly become my top blog post with thousands of views across social media platforms and other news outlets. Ellen’s Interprofessional Insights is free access to all who value its messaging, so please share the link. Now, onto my latest fierce focus. 

I was reminded last week of a long-standing pet peeve: (mis)use of the terms compliance and adherence. I participated in RISE’s Annual Population Health Summit with vibrant conversations int he space about patient engagement. Through a number of sessions there was THAT framing that makes me vibrate with frustration. My brain went into overdrive! 

When will the industry stop blaming patients for treatment inactions? Has there not been enough focus on DEI strategies to enhance practitioner and provider cultural awareness and humility? How much emphasis has there been to advance assessment of health-related social needs (HRSNs) or social drivers of health, patient health literacy, and decreasing biases? (Psssst: Remember, the CMS penalties and Joint Commission standards (TJC) are real!). Despite a resounding YES to the above questions, we’ve got miles to go before we sleep. Use of the term “compliance” instead of “adherence” by healthcare regulatory entities and organizations, plus practitioners, health systems and their and employees only condones the blaming of patients for poor outcomes. It’s time to change this practice!

Compliance Conveys Power Not Partnership

I’m notorious for level-setting and wanted to start with a review of definitions. Compliance refers to regulatory enforcement of applicable requirements whereby organizations and their providers are expected to meet or exceed the defined legal, ethical, and professional standards.Their explicit goal is to reduce fraud, abuse, and waste, with the implicit intent to ensure patient and occupational safety. Yet, there is a concerning power dynamic imposed by this definition as regulatory entities (e.g., NCQA, NQF, TJC) possess legitimate power by virtue of their role in the industry.

Compliance also implies power verses partnership. The term speaks to an assumption that patients must be subservient to a practitioner’s authority, a troublesome concept for this clinical professional. What happens when a patient’s voice is not heard or dismissed by practitioners? What about when a patient doesn’t feel seen?  These situations emerge with increasing incidence across every population, with who are marginalized and minoritized experiencing this reality in unacceptable numbers.

Compliance suggests passive behavior, as when a patient is expected to follow treatment instructions. It may be the patient who is comfortable doing what the physician tells them to, whether take a prescribed medication in a defined dose or follow-up for counseling with a behavioral health provider. Some patients may heed this guidance as the norm, not daring to question their provider, while others will seek to clarify the rationale. This approach should not be surprising in an era where patients are consumers of their care. However, questioning, challenging, or ignoring provider recommendations is too often viewed as a negative. 

Power and misused power yield trauma, whether historical, experiential or event in scope. Acute, chronic, and complex trauma share misused power and/or oppression at their source.  Blaming patients is laden with stigma and accusatory messaging. It gets me wondering how much attention is paid to a patient’s health literacy, language proficiency, or any of their concordant preferences. 


By contrast, adherence is the active choice of patients to follow through with prescribed treatments, while taking responsibility for their well-being. This term signifies that patients and practitioners collaborate to improve their health behaviors toward overall a higher state of wellness. Successful outcomes are achieved through a blend of clinician expertise with patient choice incorporating lifestyle, values, and care preferences. Shared decision-making and personal integrity leverage meaningful therapeutic relationships.

Sync for Social Needs, Z-Codes, Yet Being Out of Sync

I was excited when NCQA, NQF, and the TJC joined the Sync for Social Needs Coalition. Yet, these entities present as out of sync with their views on how to best assess and address exactly what drives patient motivation and engagement in treatment. NCQA still uses the term adherence on their resource pages and metrics. TJC echoed emphasis on patient activation and adherence in recent issue briefs.

My beloved Z-Codes are not so in sync either. ICD-10-CM Z codes for Patient Noncompliance were expanded in 2023 to my disappointment. To be fair, I’m a member of the Gravity Project and tout their work at every opportunity. However, I took a brief break from my involvement to finish my Doctoral Culminating Project. The mantra, you snooze, you lose applies!

Z-Code Z91.1 of patient noncompliance with medical treatment and regimen made me shiver. How is this concept objectively evaluated in the current care climate? Hearing colleagues refer to “non-compliant patients” always felt subjective. The terminology stirred thoughts of misbehaving children or those unable to follow traditional societal norms. 

My clinical training aligns with psychodynamic theory, thus there are always reasons for all behaviors, whether conscious or unconscious. This approach explains why a person may present as unable or unwilling to follow medical treatment. If we don’t ask why, we can’t properly assess the reasons for these behavioral manifestations. Expanding these codes gave the industry license to label patient actions as “noncompliance” with their dietary regimen and medical treatment. Caregivers of patients are also subject to these same biasesfor their “noncompliance “with an expansive list of codes under Z.91. These codes can be viewed here.

This terminology use is shocking given how the workforce is readily cued to manage their biases, stay informed of microaggressions, and participate in continuous learning to decrease missteps. Training on cultural awareness to promote patient engagement and satisfaction with care is emphasized at every turn. Yet, I am disappointed that practitioners are empowered to code, and thus blame, patients and caregivers for treatment disparities and misunderstandings.

Activating Change

Industry prioritization of health equity mandates a cultural shift in treatment language and perspectives. Here are tangible recommendations:

1. Shift the narrative and power dynamic: Practitioners and providers must shift from viewing compliant and “obedient” patients to persons provided the respect and space to partner in their treatment decisions. Autonomy and self-determination remain enduring ethical principles and amplify attention to cultural perspectives.

2. Coping with the human condition is universal: Most patients and their caregivers experience fear and anxiety about their health conditions and those of their loved ones. A majority worry about diagnosis, prognosis, and quality of life. Everyone uses some defense mechanism to cope or not (e.g., denial, isolation, projection, displacement). The reality of the health experience often occurs without warning, and usually when least expected. We must give people the grace and space to cope with it.

3. Engage to understand patient and care giver rationale: To embrace cultural awareness and humility we must seek to understand patient and caregiver behaviors. We must eliminate implicit biases rather than empower them through quality metrics and measures; “these biases reinforce blame on the patients rather than look to the system and/or the competencies of the clinicians”; big nod to my friend Michael Garrett for this quote!

4. Assess for Psychosocial Needs: This arena is a top priority for organizations and most I know are on the case to integrate reflective screening tools into their efforts. I appreciate that far more resources are needed for all of those who need them. However, let’s make sure the right team members are employed for assessment and referral of patients, including community health workers, case management assistants, and health service coordinators. The outcomes are clear about their merits to assess across the touchpoints of care for:

  • Health and digital health literacy
  • Cultural preferences for treatment (e.g., medication, provider gender)
  • HRSNs, financial, and other impediments to care (e.g., co-pays, medical debt, lack of family support, isolation, transportation, incarceration, techquity) 

5. Use Non-Judgmental Communication: It is critical we set an inclusive tone to care, including but not limited to:

  • Maintain an affirming presence to establish trust 
  • Ask the patient to verify their gender and pronouns 
  • Ask the patient to verify their race and ethnicity
  • Ask the patient to identify their family or support system, regardless of blood relation
  • Demonstrate empathic and reflective listening 
  • Respect client autonomy by allowing the person to speak 
  • Empower patient through use of open-ended questions, such as, ‘What matters most to you?” or “What can I do for you today?”
  • Respond, clarify, and confirm, instead of reacting
  • Honor the patients religious and cultural beliefs, values, and choices

(Fink-Samnick & Garrett, 2023) 

Unconditional respect between patients and providers is difficult, but not impossible. Little will change toward engaging patients in their needed care until we stop blaming them for the industry’s shortcomings.

Health Equity and the Social Determinants of Health Are NOT Synonyms

Successful health equity strategies must be inclusive, and focus on all marginalized and minoritized persons and their communities. Any lesser view will continue to yield a faulty health equity equation. 

I delayed writing this blog to not compete with a recently published article in CMSA Today on The Social Determinants of Health: Case Management’s Next Mandate. It’s a quick 5-minute read if you haven’t gotten to it yet. However, that additional week gave me time to review another important and slightly longer read, the National of Academies of Science, Engineering, and Medicine report, Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity 

Report Overview and Missteps

This well-intended report from the National Academies highlights the mandate for macro-level oversight of three disparity domains, as reflected in the title. There was affirmation how the social determinants of health and mental health (SDoH and MH) and the policies that shape them contribute to hindering and advancing health equity. Valuable recommendations included:

  • Creating a permanent federal body responsible for improving racial, ethnic, and tribal equity across the federal government
  • Development by Congress of a score card to assess the impact on health equity of all proposed federal legislation in the future, and
  • Having Federal agencies conduct an equity audit of their current policies. 
  • Collecting more accurate and complete population data for minoritized communities; those social (racial) groups that are marginalized or persecuted due to systemic oppression. 
  • Improving coordination among federal agencies
  • Supporting better inclusion of community input, and 
  • Increasing federal support and access for state and local programs.

These recommendations were sound, as the communities highlighted all face considerable obstacles in accessing optimal physical and behavioral health. Yet, the report suffers from two common flaws that I often identify when reviewing published works on this topic:

  1. Aligning health equity attainment only with the SDoH and MH, and 
  2. Viewing only racial and ethnic populations in the context of the discussion.

Health Equity and the SDoH Are Not Synonyms

Few things annoy me more than short-sighted views of the healthcare horizon in the context of our health equity challenge. I get especially irritated when health disparities are attributed to the SDoH alone. For example, I often hear presenters discuss high mortality rates for minoritized populations and attribute these poor outcomes to poverty and low socioeconomic status, unemployment, and lesser education. Maternal mortality for Black Women is >2.6 X that of White Women, though this particular data point was independent of income, education, or other elements commonly associated with health disparities. 

These faulty views impede accurate comprehension of the full scope of factors obstructing health equity, including systemic and structural racism, implicit and explicit biases, and the political determinants of health (PDoH). This erroneous perspective perpetuates generations of historical, experiential, and other event traumas endured by these populations. Patients continue to be blamed for their poor health outcomes rather than the system (and its providers) that created the chasms in care to begin with. 

Inadequate data to reflect minoritized populations has led to a risk-management ripple-effect. Faulty algorithms have been identified across clinical decision-making and interviewing models leading to inaccurate risk assessment, treatment recommendations, and medication dosages. Poor operational and fiscal outcomes intersect with quality and safety concerns, especially when the data used does not accurately reflect the clinical needs of the population. 

Health Equity Includes More than Race and Ethnicity

Achieving health equity involves taking dedicated action to improve the access, quality, and experience of healthcare for all individuals, populations, and communities. There is no doubt that race and ethnicity are key constructs for research attention and action, with abysmal morbidity and mortality rates. The National Academies report notes:  

  • Life expectancy for non-Hispanic Whites at 78.9 years of age compared to 75.3 for Blacks, and 73.1 for the American Indian and Alaska Native populations.

However, other marginalized populations face equally worrisome barriers to equitable care access and treatment. Of equal importance are gender orientation, age, and individuals with physical, cognitive, developmental, and mental health disabilities, to name a few areas. These populations are too often left out of health equity discussions:

  • Sexual and gender minority (SGM) populations have a higher incidence than non-SGM of developing chronic diseases (e.g., asthma, arthritis, diabetes, kidney disease, hypertension, cardiovascular disease, heart attack, stroke, and chronic obstructive pulmonary disease (COPD)), and more frequently deal with barriers to care from discrimination, let alone cost.
  • People living with disabilities (PLWD) have poorer health than the general population and are at a greater risk of injury and of developing non-communicable chronic diseases and age-related health conditions at earlier ages. 
  • Rampant gender disparities present in pain management, especially for those who identify as women. They experience “gendered treatment” across healthcare settings and with symptoms devalued or dismissed by their healthcare providers. This study’s results were also independent of socioeconomic status, education, or other health-related social needs.

The President of the National Academy of Medicine, Dr. Victor J. Dzau is correct that “Addressing the nation’s racial and ethnic health disparities is an imperative for the medical community.”; I would also add the priority for behavioral health given the current societal demand; after all, there is no health without mental health and visa-versa. However, efforts that limit health equity strategies to racial and ethnic disparities are short-sighted. Successful diversity, equity, and inclusion imperatives require the voice of every societal stakeholder across the entire cultural schema. 

Health Equity Actions Advance

Attaining health equity involves dedicated action to improve the access, quality, and experience of healthcare overall. This translates to intentional work by everyone, from those in data analysis, and learning and development, to persons specializing in process improvement and data measurement. This means:

  1. Developing quality metrics for health plans, health systems, and other entities that focus on more than reactive, short-term return on investment metrics, such as readmissions, patient engagement, and patient satisfaction. These antiquated data points only blame patients for poor outcomes through use of language such as “non-compliant”, rather than put accountability for change in the hands of providers. 
  2. Ensuring quality improvement efforts reduce unnecessary care utilization (e.g., ED visits, hospitalization), while simultaneously increasing access to preventative and primary care, behavioral health, and specialty care; this means adding concordant providers and approaches to care, which has been addressed in prior blog posts.
  3. Shift case management back to a proactive vs. reactive model; discharge planning is not the sole priority. Instead, case management competencies must highlight swift assessment of patients and their support systems, care coordination, interprofessional collaboration, effective communication, and outcomes management, while heeding professional ethical and compliance standards.
  4. Educate policy makers on inclusive health equity frameworks such as by Peterson et al. (2020). This robust framework accounts for equity and justice at the core of health outcomes, multiple and interacting spheres of influence, and a historical and life-course perspective (e.g., historical, experiential, developmental traumas). 
  5. Reinforce a sense of belongingness by everyone, especially persons from underserved communities. All patients and their families should feel seen, heard, and safe in the healthcare sector. This outcome can be measured by patient reported outcomes measures (PROMs), employee satisfaction and engagement surveys, and methods that involve analysis of these measures through demographics of race, ethnicity, and gender, sexual orientation, gender identity, physical and developmental disabilities, and socioeconomic status.

The Call to Action

“Our industry achieves the highest level of health for all persons, only when all voices are included. Communities that commit to health equity make all persons feel valued, and do so via concerted and ongoing attention. It is only through this all-encompassing effort that avoidable inequities are identified and addressed, historical and contemporary injustices are eliminated, and healthcare disparities are mitigated.” (Fink-Samnick & Garrett, 2023). 

Successful health equity strategies must be inclusive, and focus on all marginalized and minoritized persons and their communities. Any lesser view will continue to yield a faulty health equity equation. All populations deserve better.