Pursuing equity: The framework of the Institute for Healthcare Improvement (IHI)

Healthcare Disparities Colloquium

For the past 8 years, Main Line Health has hosted an annual system-wide Health Care Disparities Colloquium intended to identify disparities in healthcare processes and practices as they might exist—unknown to us—within our system.

The interest in research into social determinants of health through the work of collaborative interprofessional teams of faculty, residents and nurses has been significantly enhanced in our system since the opportunity to present such research projects has been afforded by the annual colloquium.

Since 2012, Main Line Health physicians and interprofessional teams have presented more than 70 research studies focusing on a variety of important topics such as:

• Health literacy
• Transportation barriers to primary care
• Food access and nutritional health
• Unconscious bias
• Disparities in stroke rehabilitation
• Disparities in outcomes of breast cancer and mother/baby mortality in the African American population

Medical Student Advocate Program

The uncovering of disparate outcomes revealed in the early Healthcare Disparities Colloquium stimulated the creation and development of the Main Line Health Medical Student Advocate (MSA) Program, now in its sixth year. The MSA program uses volunteer medical students from Philadelphia College of Osteopathic Medicine to help identify nonmedical barriers to care and connect patients to established resources in order to address their needs.

The MSA program provides future physicians with a unique educational opportunity that allows them to develop skills in establishing doctor-patient relationships, understanding the psychosocial factors shaping health outcomes and engaging with other healthcare professionals.

MSAs are embedded in patient-centered medical home teams at Lankenau Medical Associates, an internal medicine and subspecialty residency practice at the Lankenau Medical Center, which serves many of our most vulnerable patients.

Patient-centered medical home teams comprise nurses, social workers, nurse practitioners, health educators, physicians and medical assistants. Through a social need survey screening tool, MSAs identify a range of nonmedical patient needs, including transportation, child care, food access and utility assistance.

Patient surveys are reviewed at a patient-centered medical home team meeting dedicated specifically to addressing psychosocial needs. Subject to survey outcomes and patient willingness, patients are triaged to social workers, health educators, case managers or an MSA for follow-up. This interprofessional team-based care incorporated into a weekly interprofessional forum provides for improved care coordination and population health management.

The program has expanded to include five clinical sites, including Main Line Health's Lankenau Medical Center Emergency Department (a level II trauma center) and Spectrum Health Services, a federally qualified health center in West Philadelphia. Since 2012, at Main Line Health, a total of 102 MSAs have served 1,513 patients, identified 3,688 nonmedical needs and provided 1,535 referrals to community resources for patients.

ED High Utilizer Study

Integrated with the efforts of the MSA program, Lankenau Medical Center initiated a project to analyze the underlying nonmedical needs (such as transportation, utilities, food insecurity and housing) that might lead to the high frequency of ED visits by members of the vulnerable populations who have become known as “ED superutilizers.”

In this pilot project, an interprofessional team-based approach was used to identify and address the medical and psychosocial needs of patients who had been “treated and released” from the Lankenau Medical Center Emergency Department more than three times over a 15-month period.

An interprofessional team was established including a nurse case manager, primary care physician, nurse practice manager, social worker, clinical psychologist, hospital administrator, MSA, ED nurse, nurse manager and medical assistants.

Greener Partners, an organization working to create healthier communities through food, farms and education, partners with Main Line Health to develop and to maintain the Delema G. Deaver Wellness Farm at Lankenau Medical Center.

Lankenau Medical Center was built nearly 75 years ago on a golf course, the rolling hills of which allowed for the creation of the Delema G. Deaver Wellness Farm at the Lankenau Medical Center. Through research at the Main Line Health Center for Population Health, we became aware that only 10% of adults in West Philadelphia eat adequate servings of fruits and vegetables daily. In this geographic region, approximately 34% are obese and about 27% have multiple chronic diseases.

Our vision is to use the Delema G. Deaver Wellness Farm to improve access to healthy foods for this population, reinforcing the link between nutrition and health and supporting primary care providers in identifying and addressing food insecurity.

Lankenau Medical Center collaborates with Greener Partners, whose farm experts have helped us plan and continue to support us to maintain a year-round organic, half-acre farm on our hospital campus that is now fully integrated into healthcare delivery. The goal is to harness the power of locally grown food to strengthen our community’s health.

For the past 4 years, the Deaver Farm has been harvesting over 30 different types of produce. The farm offers the opportunity to expose patients to the benefits of fresh fruits and vegetables at regular appointments with their primary care provider or with their OB/GYN provider. Pop-up “farmers’ markets” (produce is offered at no cost to patients but presented in a farm stand format) and nutrition demonstrations provide opportunities for patients to receive free produce and nutrition education. Education generally includes a recipe provision and meal preparation demonstrations.

By holding these activities in a primary care setting, we meet the patients where they are—without adding the additional burden of travel. It also offers an avenue for providers to open a discussion around healthy eating and nutrition. The farm offers the opportunity to address the food insecurity and chronic disease management needs of Main Line Health’s most vulnerable patients and supports population health initiatives in demonstrating how hospitals can play a vital and important role in creating a culture of health.

Lankenau Medical Center is located at the intersection of two designated communities: the “Main Line” suburbs of Philadelphia—associated with wealth—and West Philadelphia, which over recent decades has come to be seen as an under-resourced community. The Main Line is situated in Montgomery County, which usually carries a designation as one of the healthiest among the 67 counties of Pennsylvania, whereas West Philadelphia is a component of Philadelphia County, now regarded as the 67th of 67 counties in health ranking.

Stimulated by the Institute for Healthcare Improvement (IHI) Pillar 5 and supported by IHI leadership, the Main Line Health IHI team reached out to academic and community partners in and surrounding West Philadelphia to “break silos” and to seek collaboration—based on an assumption that through collaboration, the impact of advocacy could be maximized. Together for West Philadelphia—a collaborative (and now, a 501c3 organization) within West Philadelphia among more than 20 community, public and private sector stakeholders—was born to foster shared projects to maximize impact in the areas of health, education, food access and opportunity.

The board of 28 volunteers has operationalized the organization’s work into six subcommittees, substantially corresponding to the socioeconomic determinants of health:

• Health equity
• Education
• Food justice
• Employment
• Housing
• Senior well-being

The fledgling organization is privileged to have the encouragement and support of our U.S. Congressional representative whose constituents live in the five zip codes that constitute Together for West Philadelphia’s focus area.

Research shows that level of education is a key determinant of predictable life span and health quality. So, we began to explore how to make a meaningful contribution in addressing inequities in education—even when the primary mission of the health system is healthcare, not early education.

In 2007, Lankenau Medical Center developed the Health Career Collaborative, an educational enrichment program in a neighboring public high school whose dropout rate approximated 40% to 50%. The mission of the program is to support youth in disadvantaged areas to:

• Graduate from high school
• Gain health literacy
• Pursue postsecondary education
• Develop interest in health careers

Main Line Health enlisted medical students at Philadelphia College of Osteopathic Medicine to serve as volunteer program mentors and instructors. The mentors worked with 10th graders, using the theme of exciting ED cases as the basis for discussion of important social issues and health topics impacting the community. After demonstrating success, three additional medical school–high school alliances were formed in the Philadelphia area:

• Sidney Kimmel Medical College at Jefferson University
• Drexel College of Medicine
• Lewis Katz School of Medicine at Temple University)

The four groups began working as a coalition under the direction of Main Line Health’s chief academic officer and a cohort of experts in education.

With financial support from the Aetna Foundation, eleventh and twelfth grade curricula were established, and in 2014, the program was successfully replicated in Atlanta, demonstrating that the Health Career Collaborative could be implemented wherever there are students in need of engagement and enthusiastic mentors ready to engage them.

As a primary goal of the program was to introduce the broad spectrum of health careers to the underserved classroom, medical students found themselves partnering with nursing students and students from the allied health professions in a collegial effort to expose high school students to the processes and rewards of their own professional studies.

This interprofessional collaboration at the mentor level was expanded to include members of the various local chapters of the National Association of Health Services Executives, whose members represent a wide range of administrative careers in healthcare. This partnership allowed Main Line Health to broaden exposure to the wide scope of careers in healthcare, provide additional networking and educational opportunities to motivate high school students and enhance the interprofessional dialogue of student mentors.

In 2018, the Health Career Collaborative was adopted by the American College of Surgeons as a domestic offering of community volunteerism in its initiative called “Operation Giving Back,” and the program has spread rapidly ever since. The program is now in 13 cities and includes partnerships between 22 medical schools and 26 high schools.

The program’s easily reproducible curriculum, as well as instructional videos and materials, is accessible through the Health Career Collaborative's website. From this website, student mentors can review lessons, print materials and watch instructional videos designed to explain best program practices. 

The creation of web-accessible, easily reproducible curricula is intended to minimize preparation time required by volunteers and increase the potential for participation. Each site’s implementation is assessed and supported by the Health Career Collaborative national program director who meets with faculty and medical students virtually on a regular basis.

The Health Career Collaborative has reached over 2,500 high school students. Post participation surveys (2014–2018) demonstrated that the program is well liked by students, appreciated by their teachers as a focus of student engagement, and feasible to replicate.

Tenth grade students reported the Health Career Collaborative helped them learn about different healthcare career options, plan for how to reach career goals and understand how healthcare workers care for patients. Eleventh-grade participants noted the program made them aware of the importance of public health and taught them about medical conditions, selfcare and safety.

A high percentage of students—86% of 10th graders and 71% of 11th graders—reported they're considering healthcare careers. Teachers noted that participants learned broadly applicable skills and that the program stimulated interest in health-related careers and created optimism about furthering education.

Academy Relationships with the high school students in the Health Career Collaborative resulted in the realization that there's a lack of educational opportunities for youth in under-resourced areas in the summer. It's been shown that students without satisfactory intellectual stimulation during the summer experience a phenomenon often referred to as “summer slide,” which results in loss of academic gains from the prior school year.

An awareness of these facts and our system achievements with the Health Career Collaborative program led us to work with academic partners in our surrounding community to jointly sponsor a series of Health Career Summer Academy camps. The primary goal of the camps is to broaden the perspectives of impressionable students by reinforcing the importance of education and demonstrating how they can apply science and health concepts to a variety of attainable careers in healthcare.

The Health Career Summer Academy began as a one-week pilot program for middle school students of the Chester Upland School District on the campus of West Chester University and was a major success. The program has since been replicated at Rosemont College, Arcadia University, Saint Joseph’s University, University of the Sciences and Friends’ Central High School. The college or school supplies the grounds and counselors (college student role models) and establishes a plan for recruiting campers, focusing on students who live in an environment in which barriers to educational success exist. The health institution and college collaborate to develop a one-week curriculum suitable for student engagement and appropriate for the training and interests of the camp counselors.

Our research shows that the Health Career Summer Academy has a positive impact on student participants. Based on self-reporting, participating students are more interested in attending college and pursuing a career in healthcare in the future and more motivated to perform well in school.