UMass Memorial Health, the largest health care system in Central Massachusetts, identified a disparity among families belonging to a minority group who were more frequently missing well-child appointments. This disparity was identified as a “critical threat” to communities that been historically marginalized or made vulnerable.
As a safety-net healthcare system, UMass instituted a system wide performance improvement project with a goal of improving attendance at well-child visits among Blacks/African American and Hispanic families by five percent over one year.
Josephine Fowler, MD, a board-certified family medicine physician who serves as Clinical Vice Chair of Family Medicine and leads the UMass Family Medicine clinics, served as the family medicine leader for this multi-physician work group.
With full support and funding from leadership, a multidisciplinary team set out to identify and strategically reduce barriers that impacted access to care. A subsequent aim of the project was to identify possible social determinants of health preventing families from scheduling or following through with well-child appointments at four UMass Family Medicine clinics involved in the project.
"We decided to look further than just the business, and look at why the gaps existed,"
Dr. Fowler
Well-child visits are tracked in electronic health records; however, practices were unable to leverage the health record data to evaluate racial variances. Therefore, the UMass Population Health Analytics Team in the Office of Clinical Integration developed a “health equity dashboard” to help practice leaders and clinicians track real-time performance reviews of race, ethnicity, and language preference unique to their setting. As a result, disparities were identified sooner, allowing for interventions to reduce the number of missed appointments or use of the emergency departments in non-critical situations.
Qualitative interviews with caregivers, parents, and healthcare staff yielded insight into root causes, which included language barriers, scheduling difficulties, and transportation challenges. Patients at risk for missing appointments were provided flyers, available in several languages, citing the importance of routine well-child visits. In one setting, parking fees were identified as a primary barrier. The team has since worked to improve parking voucher access for at-risk populations. This is currently being put in place and will be evaluated to confirm the service improves attendance to well-child visits.
In a 12 month period during the pandemic, participation in well-child visits increased 16% among Black families and 12% among Hispanic families. According to an article published in the Joint Commission Journal on Quality and Patient Safety, 34,142 patients (ages 0-21) were served with improved patient engagement and culturally appropriate health care delivery strategies across the 53 practices providing family medicine and pediatric care.
Dr. Fowler used the ABFM Health Disparities/Equity Self-Directed Performance Improvement (PI) activity to report her role in this project, the impact on patient outcomes, as well as why disparities exist. “We’ve really improved our ability to seek out the patient who has not been able to keep their appointment,” said Dr. Fowler. With the implementation of an enhanced reminder system, Dr. Fowler notes patients feel a “larger sense of belonging, because somebody cared enough to help facilitate their ability to take care of their health.”
Fowler also reports this project confirmed the presence of health equity knowledge gaps among providers, which has resulted in improved understanding of social determinants of health (SDOH) and barriers that patients face when accessing healthcare and other public services. “I find value in developing and being a part of these projects,” said Dr. Fowler. “You get to know what the requirements are, and while you’re participating in the project, you really get a full understanding of evidence-based practice.”
The UMass team will continue to pursue health equity initiatives system-wide and emphasized that it is possible for other health systems to examine data and align procedures appropriate to the uniqueness of each location and population served.
