The impact of health and social disparities is well documented. The impact is not only directly experienced by historically underserved and marginalized populations but has an impact on all of us.

According to a Deloitte Insights article¹ on the economic cost of health disparities,

Our actuaries concluded that health inequities account for approximately $320 billion in annual health care spending signaling an unsustainable crisis for the industry. If unaddressed, this figure could grow to $1 trillion or more by 2040. If the United States reaches this threshold, we could see a direct impact on affordability, quality, and access to care beyond the challenges that already exist.”

The impact of health and social disparities

Disparities in health and social care have a dire impact on communities of color, the LGBTQ+ community, and adults with disabilities, among others. Just a few examples of these disparities and their impact on quality of life, lifespan, and economic costs:

• Native Americans and Alaska Natives have a life expectancy that is 5.5 years less than all other US populations²
• COVID: People of color were more likely to die at a younger age than whites³
• People with disabilities, some racial and ethnic minority groups, those in rural areas, and lower income populations are more likely to encounter barriers to accessing health care⁴
• Increased morbidity and mortality rates among affected populations⁵
• Hispanic women are 20% more likely to die from cervical cancer than non-Hispanic White women⁶
• Health disparities account for roughly $42 billion in lost productivity per year¹

The U.S. Department of Health and Human Services (HHS) has developed a strategic approach to address social determinants of health (SDOH). The approach will “guide efforts to make health outcomes more equitable by better coordinating health and human services. It is estimated that clinical care accounts for only 20% of the county-level variation in health outcomes, while SDOH account for as much as 50% and are a major driver of health disparities.” Further, The U.S. Playbook to Address Social Determinants of Health released in November 2023 provides information on federal agency work, the role of backbone organizations such as community care hubs (CCH), toolkits, and other resources useful for CBOs and other SDOH stakeholders.

This is a vital opportunity for CBOs and evidence-based program (EBP) providers to be part of the solution in addressing SDOH. Educating health systems, your community, and your state leaders about the services your organization provides and participating in a CCH can be key parts of a strategy to secure funding to grow capacity to serve more individuals and families in the community. Being adept at serving diverse communities is critical to providing needed services to address SDOH. Assessing your internal organization’s ability and proficiency to reach and provide services to underserved and diverse communities is a first step in determining what conversations, training, leadership, staff, and/or collaborations are needed as part of an ongoing process.

Understanding the language of diversity, equity, and inclusion

To develop and incorporate strategies to reduce health and social disparities, it is helpful to have a common understanding of what is meant by social and health disparities, health equity, diversity, inclusion, equity, and person-centered care. There are variations in the definitions depending on the organizational authority used. However, the principals and elements generally share key commonalities.

Health and social disparities are defined "as a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion."⁷

CMS defines health equity as "the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes.”⁷

While the term diversity, equity, and inclusion (DEI) is used frequently, it is important to understand the distinctions between diversity, equity, and inclusion.

Diversity is the representation of multiple identity groups and their cultures. Race, religion, ethnicity, sexual orientation, disability, language, culture, etc. A unique person or groups of people within a larger majority of people.

Equity recognizes differences in people and focuses on giving everyone the best opportunity to meet their maximum potential.

Inclusion is an environment in which all individuals are treated fairly and respectfully, have equal access to opportunities and resources, and can contribute fully to an organization’s success. The literature often focuses on a work environment; however, it is applicable to a CBO serving a diverse community whether it be by group identification or geographic location. The CBO needs to be cognizant of providing equal access to resources, services and opportunities and help its consumers feel included by being treated fairly and respectfully.⁷

Person-centered care, at its core, is an approach that identifies and is responsive to an individual’s strengths, goals, preferences, values, medical and social care needs, culture, and desired outcomes.  Respect, building of trust, and communication in the individual’s language are essential to the process. Similarly, these principles or concepts are embedded in person-centered planning often used by CBOs to identify and meet social care and health needs. Many evidence-based programs embody person-centered approaches in their curriculum to successfully help individuals to modify their behaviors for better health and quality of life outcomes.

Evolving health care standards

Non-discrimination and DEI are embedded in American law, regulations, and court rulings. For example, the Older Americans Act (OAA), Americans with Disabilities Act (ADA), and Title VI of the Civil Rights Act of 1964.

Increasingly, DEI principles are being incorporated into health care standards to effectuate change to bring about health equity for all individuals. Accrediting and other health care entities are recognizing the evidence showing that to raise the quality of health care and maintain sustainable costs it is a necessity to reduce health and social disparities and move toward health equity for all populations.

For example, the National Committee for Quality Assurance (NCQA) has been integrating equity into its mission, standards, and measures. NCQA refers to it as “The Big Idea” to advance health equity. “It builds on three ideas:

1. High quality care is equitable care
2. There can be no quality without equity
3. NCQA needs to integrate health equity into everything it does”

Subsequently, “NCQA has identified four ways the Healthcare Effectiveness Data and Information Set (HEDIS) can advance health equity:

• Bring transparency to quality inequities
• Promote inclusive approaches to measurement and accountability
• Address social needs to improve health outcomes
• Incentivize equity with benchmarks and performance scoring.”

The result, NCQA began adding race and ethnicity stratification to HEDIS measures in 2022 to identify health disparities and in areas where such disparities may not exist to learn how to improve health equity. In measurement year 2024, they are expanding the race and ethnicity stratification to include 9 additional HEDIS measures, bringing the total to 22 thus far.

• The Joint Commission, which evaluates and accredits over 22,000 hospitals, other healthcare entities and programs in the U.S., has added new goals and standards to advance health equity for all people.  They have adopted a “vision that all people always experience safe, high quality healthcare.”
• The U.S. Department of Health and Human Services (HHS) Healthy People 2030 contains measurable objectives to advance elimination of health disparities, achieve health equity, attain health literacy and address social determinants of health needs.

DEI as a Strategic Business Imperative and Value Proposition

As a business organization, there is more and more pressure on businesses from a regulatory perspective or going forward from a society or community perspective to reflect values that share equity with the communities that you serve. It’s embedded in Medicare, Medicaid, and the Older Americans Act. More and more funders and states are looking at how to improve diversity, equity and inclusion in the development of programs and contracts they let. --Sharon Williams, CEO, Williams Jaxon Consulting, LLC

The perspective of the corporate world, which is increasingly integrating DEI into its mission and business infrastructure, may provide valuable insights for CBOs. Some corporations have been doing this for years while others are more recent adapters. A panel comprised of executives from Gannett Co. Inc., NBCUniversal Media LLC, Bandier Commerce LLC, and a retired senior partner at Ernst and Young participated in a webcast hosted by Cornell SC Johnson College of Business to discuss The Business Advantage of DEI Across Industries. The panelists spoke about the importance of DEI becoming part of the corporate culture, leadership from the top, need for champions, and implementing activities and strategies to incorporate it into internal operations and externally. They also talked about resistance, challenges, and strategies to address these, as well as investment of time and resources to be impactful.

Reasons the panelists provided for corporations working to incorporate DEI into their business operations and practices include:

• Attracting a creative and innovative talent pool
• Improving employee retention
• Expanding the customer base, and reaching new markets
• Creating new competition
• Risk management in terms of reducing internal grievances, external complaints, or legal actions resulting in real or perceived non-compliance with civil rights, employment, Americans with Disability Act (ADA), and other non-discrimination laws and regulations

For community-based organizations, incorporating DEI into the fabric of their mission and business infrastructure/environment can help you better serve your community and provide person-centered care as well as positively impacting health-related social needs and health outcomes, open doors to new funding opportunities, and attract and retain employees.

Developing and incorporating DEI strategy in your organization

One size does not fit all, just as all communities are not the same.  It is important to do research and understand your organization, the community you serve, and the communities you may be seeking to serve.

Some elements to consider (from Sharon Williams, CEO, Williams Jaxon Consulting, LLC):

• Leadership and champions (executive, senior management, board members, advisory boards, and champions at different levels of the organization)
• Conduct research to identify community needs and to understand the entire community
• Integrate DEI into the organizational mission and throughout the organization's infrastructure and operations. Embed in all programs and service delivery
• Strategic planning
• Policies and procedures that are implemented, not sitting on a shelf
• Set measurable goals, objectives, and action steps
• Commit to and invest in sustainability of DEI practices
• Develop a business case or value proposition (can be used internally and externally)
• Training on why DEI is important, what it is, how to integrate it into programming and service delivery, etc.
• Establish DEI workgroups and/or employee resource groups
• Include dissenters in DEI development and workgroups (important to hear the feedback of those resistant—it's part of being inclusive)

Intersection of cultural humility, SDOH and DEI

Person-center care is premised on being respectful and responsive to the individual’s preferences, needs and values.  It involves the patient or client being fully engaged in the decision-making of what is occurring in their life. It can be challenging for helping professionals who may believe a different decision might be better based on their own knowledge and experience.

It is another way to look at why DEI is so important and how the practice of cultural humility can be impactful.  Cultural humility is a reflective process of being respectful of other cultures, open to other people’s identities and life experiences, being aware of your own beliefs and any biases, and managing power imbalances.

In summary, adopting DEI is important for CBO and EBP providers. Most, if not all, CBOs have a core mission to improve the lives and communities they serve. Incorporating DEI furthers achieving the mission.

This leads to relaying a story that speaks to the intersection of cultural humility, SDOH, and health care and being person-centered. 

After a training session, a visiting nurse expressed to the trainer her frustration with a grandparent who canceled an appointment to take her infant grandchild to the doctor for the third time. The nurse made some statements to the trainer that revealed some biases. The trainer inquired if the nurse asked why the grandparent kept cancelling the appointment. The nurse had not. After the next training session, the nurse approached the trainer to say that she thought about it and asked the grandparent why. The answer was the grandparent did not have a snowsuit for the baby and its freezing outside. The nurse got a snowsuit and warm clothes for the baby and the grandparent took the baby to the doctor.

Being willing to ask questions, attentively listen and learn can be a good place to start the DEI journey. A CCH may be able to provide technical assistance, share community research to help your organization understand new communities or populations or other elements of DEI. Once a culture of DEI is embedded into your organization, it remains a continuous journey as organizations change, as do the communities you serve, requiring continuous commitment and attention.

Go deeper:

To assist ACL evidence-based falls prevention and chronic disease self-management grantees as well as other community-based service providers, NCOA held four webinar sessions to inform participants about coordinated networks of CBOs led by community care cubs (CCH). Community care hubs and their network partners often start with one or more Evidence Based Programs (EBPs) as their first service offerings.

Each of the webinars focused on different core roles and responsibilities that are important when considering and participating in a CCH. Some themes cross multiple webinars such as contractual commitments for delivery capacity, quality, performance measures, IT security and data integrity. These companion articles provide key highlights and information associated with each webinar. Other relevant information and resources are shared in the articles where appropriate. We encourage you to listen to the webinar and view the PowerPoints to get the full benefit from the webinar series.

Webinar #1: The Important Role of Evidence Based Program Service Delivery Providers in Community Care Hubs – February 28, 2023  

Webinar #2: Quality, Fidelity, and Compliance Expectations for Service Delivery Providers - March 23, 2023  

Webinar #3: The Essentials of Data Sharing in a Coordinated Network of CBOs, April 27,2023  

Webinar #4: Diversity, Equity, and Inclusion: Establishing Standards Across Service Delivery Providers, Leaders and Volunteers, May 23, 2023  

Resources

Social determinants of health/health equity:

• SDOH-Action-Plan-At-a-Glance.pdf (hhs.gov)
• CMS Strategic Plan Health Equity Fact Sheet
• CMS Framework for Healthy Equity 2022-2023
• Promising Practices to Address Health Disparities (National Academy for State Health Policy)
• Principles of an Equitable Health and Social Care Ecosystem
• Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes
• Leveraging Healthy People to Advance Health Equity (Healthy People 2030)
• Culturally and Linguistically Appropriate Services - Think Cultural Health (hhs.gov)
• Principles of an Equitable Health and Social Care Ecosystem (Partnership to Align Social Care)
• Guidance for Health Care Entities Partnering with Community-Based Organizations 

Standards:

• Stratified Measures: How HEDIS Can Enhance Health Equity - NCQA
• Data and Measurement - NCQA
• Equity and Quality Connection – The Joint Commission
• National CLAS Standards – Think Cultural Health
• Updated Medicare Reimbursement Rule Addresses Health-Related Social Needs and Care Coordination

Cultural humility:

• Core Values Statement - Advisory Committee on Minority Health - Office of Minority Health
• Improving health equity through the practice of cultural humility – United Healthcare
• Cultural Humility Improves Patient Experiences, Health Outcomes, Hospital Readmissions – RTI Health Advance
• Cultural Humility Is Critical to Health Equity

Diversity training and messaging:

• Caring for Those Who Care – Diverse Elders Coalition

Corporations and DEI:

• Cornell University. (2022, September 28). The Business Advantage of DEI Across Industries – Trends, Impacts, and Best Practices.  Keynotes - eCornell. 
• RWJF’s Structural Racism and Health Messaging Guide

Data, research and IT:

• Advancing Health Equity Requires More and Better Data
• Disparities in Patient Access to Electronic Health Information: Insights from a National Survey - Health IT Buzz Health IT Buzz
• Objectives and Data - Healthy People 2030
• New Releases: SDOH Toolkit and Learning Forum Sessions for the Health IT Community
• Social Determinants of Health Information Exchange Toolkit
• Understanding Health Disparities Series - NIH

Person-centered care/planning:

• Cultural Considerations for Person-Centered Planning: A Companion Guide to the NCAPPS Culture and Person-Centered Practices Shorts
• Person Centered Planning - ACL
• What is Person-Centered Counseling? – No Wrong Door
• Person-Centered Care - CMS
• Person-Centered Care: A Definition and Essential Elements

This project was supported, in part by grant number 90CSSG0048 and 90FPSG0051 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

Sources

1. Davis, Andy, FSA, MAAA, et  al. US health care can’t afford health inequities. Deloitte Insights. June 22, 2022. Found on the internet at https://www2.deloitte.com/us/en/insights/industry/health-care/economic-cost-of-health-disparities.html 

2. Indian Health Service. Disparities. Found on the internet at https://www.ihs.gov/newsroom/factsheets/disparities/

3. Matthew McGough, et al. Racial disparities in premature deaths during the COVID-19 pandemic. Peterson-KFF Health System Tracker. April 24, 2023. Found on the internet at https://www.healthsystemtracker.org/brief/racial-disparities-in-premature-deaths-during-the-covid-19-pandemic/

4. Centers for Disease Control and Prevention. What is Health Equity? Found on the internet at https://www.cdc.gov/healthequity/whatis/

5. Eliseo J. Pérez-Stable, MD and Monica Webb Hooper, PhD. The Pillars of Health Disparities Science—Race, Ethnicity, and Socioeconomic Status. JAMA Health Forum. Dec. 21, 2023. Found on the internet at https://jamanetwork.com/journals/jama-health-forum/fullarticle/2812750

6. The Joint Commission. Impact of Disparities in Health Care. Found on the internet at https://www.jointcommission.org/our-priorities/health-care-equity/#1c0fa8fb8a5345d8aa734418e10a8869_b5202a8bfaf2454cbea9b2814c9220f7

7. Diversity, Equity, and Inclusion: Establishing Standards Across Service Delivery Providers, Leaders, and Volunteers. Slide 13. Found on the internet at https://connect.ncoa.org/products/diversity-equity-and-inclusion-establishing-standards-across-service-delivery-providers-leaders-and-volunteers?packages%5B%5D=135292&in_package=135292&sort_by=package_order&ref=package&ref_id=135292