Quality Cancer Care for All: An Equity Toolkit

Quality Cancer Care for AllAn Equity Toolkit

Bob GardnerSignature Event: Removing Barriers to Cancer Care for All

Cancer Quality Council of OntarioNovember, 2013

Problem to Solve → What Success Looks Like

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no inequitable access barriers• all along the patient

trajectory • all across an integrated

system best quality for all• and geared to

different/greater needs of health disadvantaged populations

→ best outcomes for all

Social determinants of health: Inequitable gradient of prevalence &

burden Inequitable personal/community resources

to cope with cancersInequitable care/patient experience: Discrimination Inequitable rates of screening Inequitable barriers along the patient

journey: screening, diagnosis, treatment, post-treatment support

Specific barriers: language, costs of medication, transportation & ancillary services

Inequitable gaps in continuity of care: Availability Continuum of care Integration of services Provider Awareness of options available to

patients

Towards SolutionsIf we can identify those gaps and barriers and unmet needs, we can act on them• will set out a toolkit of ideas,

directions and tools to build equity into cancer care planning and delivery

• solidly based in research evidence and years of best practices

• action-orientated and manageable• measureable – so can monitor and

assess progress• adaptable to specific organizational

and local contextsthe particularly good news = don’t need to start from scratch

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1. Start from Solid Foundations

• high-performing healthcare systems – whether cancer care or province-wide -- build equity into all planning and service delivery• doesn’t mean all programs are all about equity• does mean all programs and planning need to take equity into

account• need clear strategic commitment to build equity into

system as a whole• cascading throughout all providers and programs so that equity

becomes part of working culture across the system• commitment has to be backed up by resources for equity

planning and operationalization

| www.wellesleyinstitute.com

2. Into Practice Through Equity-Focused Planning

• addressing disparities in access to or quality of cancer care requires a solid understanding of:• the contours and scale of inequitable outcomes• the specific needs of health-disadvantaged populations• gaps in available services for these populations• key barriers to equitable access to high quality care along

patient journey• at delivery level = considering equity in all program planning

• e.g. given importance of communications and understanding to quality care → need to ensure cultural competence, access to interpretation wherever needed, etc.

• need effective and practical equity-focused planning tools

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3. Collect Equity Data

need solid equity-orientated data• to identify gaps and needs of

disadvantaged patients• to measure and monitor progress

pilot project in 3 Toronto hospitals (and Toronto Public Health) to collect patient SDoH type data scaled up to all hospitals in Toronto Central LHIN valuable website of resources on how to collect and use this data

Action idea = adapt and use framework in all cancer care settings

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4. Build Knowledge We Can Act Onresearch base includes:• epidemiological – scale of disparities,

disadvantaged communities/groups• community-based research = especially

unique understanding of needs and interests of marginalized or excluded populations

• ethnographic = nuances of experience along patient journey

• evaluation – need to know what works well, for which populations, in varying contexts

Action idea = widen the types of research supported

systematic data collection + ability to measure/monitor /evaluate + rich research evidence = knowledge to guide/ground action

5. Beyond Planning: Embed Equity Into Targets, Deliverables and Performance Management

• clear consensus from research and policy literature, and consistent feature in comprehensive health equity policies from other jurisdictions: • developing realistic and actionable indicators for more

equitable service delivery and outcomes• setting targets for reducing access differentials, improving

health outcomes of particular populations, etc• monitoring progress against the targets and indicators• disseminating the results widely for public scrutiny• aligning performance with funding incentives and resource

allocation• Action idea = embed equity into comprehensive

performance measurement and management strategy

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5 a. Success Condition = Effective Equity Targets

• innovative work underway to develop equity indicators – but don’t need to wait

• pick what is most relevant to your context:• do rates of post-treatment recovery and hospitalization vary

inequitably – by geography, ethno-cultural background, socio-economic status?

→ equity target = reduce inequitable differences• build equity into existing targets:

• e.g. increasing rates of screening and reducing wait times between diagnosis and treatment are system goals

→ equity target = reduce inequitable differences in rates between different populations or areas

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6. Embed Equity Into Organizational and System Drivers

• quality improvement is major provincial and system priority → embed equity

• part of quality + equity = customized care to meet differing needs• social determinants disadvantaged populations face greater barriers

beyond the hospital walls • availability/cost of transportation, childcare, poor living conditions,

inequitable access to community services, discrimination, being able to afford medication)

→ effective continuum of care and effective navigation/transitions is especially important for marginalized→ e.g. more intensive case management, referral planning and post-discharge follow-up for those in more challenging/isolated conditions

• tool = take a social history as well as medical history


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6 a. Use Proven Tools: Equity Standards

Canadian Health Equity Standards Working Group

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6 b. Indispensable Foundation for Equity Into Quality = Cultural Competence

• in an increasingly diverse society, high quality care = culturally competent care

• means building equity and diversity into all facets of service delivery:• means customizing care to address language and other barriers people may

face and to their cultural preferences and needs= where structural analysis and knowing your patients meets quality care• not just service delivery, but everywhere – e.g. security, receptionists

• + organizational commitment• supported by resources – esp. for training• linked into concrete performance expectations and deliverables• diversity equity and other ‘soft’ services can be vulnerable in tough fiscal times

• Action idea: ensure cultural competence strategy, resources and targets work well across the cancer care system


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7. Use Available Levers To Embed Equity

• providers are required to develop QIPs = major lever for driving QI • equity should be one of dimensions providers must report on – but wasn’t

really in hospital plans so far = missed opportunity• no reason why individual providers can’t decide to incorporate equity into

their QIPs→ immediate benefits of embedding equity into quality improvement→ necessary cross-hospital collaborations and discussions will help to embed equity in every-day working culture

• Action idea: all cancer care programs and institutions to build equity into their QIPs

• providers sign accountability agreements on cancer care to be delivered, funding, etc.

• Action idea: build equity deliverables into provider accountability agreements


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8. Target Access and Quality Barriers

improving equity requires identifying and addressing specific equity barriers • within delivery – language, lack of understanding of different cultures,

differential treatment, prejudice and discrimination, accessibility• beyond the hospital – e.g. sent home with follow-up prescriptions, but

don’t have a drug plan; can’t come into clinic for follow-up because of family responsibilities

• most important barriers will vary → back to importance of data and understanding health needs of community

tools = population health profiles, health equity audits to identify most important barriers and gaps in your settings


8 b. Barrier = Under-Served PopulationsSolution = Focused Community Partnerships

• lower screening rates in particular ethno-cultural or disadvantaged groups

• e.g. South Asian women in Peel→ community-based research to assess why→ broad partnerships of Public Health, providers and trusted community organizations to get beyond barriers→ outreach to diverse community settings where women live, work or go

Action idea: explore innovative community-based models like ‘peer health ambassadors’

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9. Build Community Partnerships

addressing wider social determinants of health and roots of healthier communities means working in broad partnershipsmore immediately for good cancer care, partnerships :• can better reach under-served• collaboration with community

agencies = essential to effective follow-up and referrals

• the good continuity of care, navigation and transitions for the most vulnerable requires web of community support

• community-based support can help mitigate harsher effects of poor living conditions and isolation


Pull All This Together into a Strategic

Roadmap

• from a large toolkit, develop a roadmap of what sector will do

• can’t be a rigid blueprint, needs to be adapted and implemented flexibly to contexts and circumstances

• but need clear sense of direction and overall goals

• needs to pull various initiatives into a coherent and connected plan

• Action idea: CCO, CQCO and stakeholders to develop a system wide equity plan

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Goal Today: Land on Action Initiatives

1. adapt and implement equity-relevant cancer care data→systematically collect across the system→build into measurement and monitoring

2. build equity into system and provider performance management• adapt most relevant indicators, deliverables and incentives for

this context• use proven tools like standards, HEIA to operationalize

3. build community partnerships• to address access barriers, unmet needs and populations left

behind• to build a web of support for people with cancer


Quality Cancer Care for All: An Equity Toolkit

Healthcare

equity planning

equity data

equity indicators

cancer care planning

solid equityorientated

quality cancer care

quality of cancer care

system goals equity