The Future of the Fight Against Health Disparities
Innovative Care Evolving for Latino Population
UT Health San Antonio cares for a massive underserved Hispanic-majority region where health disparities are rampant, and thus prevalence of diabetes, cancer and dementia are higher than the rest of the nation. These disparities are so diverse and complex in origin that some policy experts have despaired of ever bridging them.
Finding narrow cracks in the health care delivery system and bridging them is the passion of Amelie G. Ramirez, Dr.P.H., chair of the Department of Population Health Sciences at the Joe R. and Teresa Lozano Long School of Medicine. For example, her team at the Institute for Health Promotion Research (IHPR), where she is the director, discovered that Hispanic cancer patients often failed to return to a primary care provider after cancer treatment was completed, for several reasons. Some patients did not have a primary care provider in the first place, and others were worried about the debt they incurred, even just from co-pays, so they avoided further physician visits. This loss of transition of care for Hispanic cancer patients resulted in a decrease in screening for cancer relapse, and thus harming ultimate outcomes.
Dr. Ramirez hypothesized that the health care team needed to meet these cancer patients in their homes to personally assist them in transitioning from cancer care to primary care. She created multiple strategies to utilize community health workers (CHWs) to improve overall cancer health in these minority populations.
“Community health workers have been utilized in different settings, but the model we are developing is to show they have value and can contribute to helping make patients more compliant with their physician’s recommendations,” said Dr. Ramirez said. Using them to bridge transitions of care is one example of an innovative mechanism by which they can be used to have real impact on cancer survivorship.
Patients are impacted by the cultural, educational and economic limitations to productive use of the health care resources available. “Through the community health worker, we help them connect with some of those community services that can reduce some of the stresses in their lives so they can think about ways to improve their health,” Dr. Ramirez said, emphasizing value-based care.
Such innovative approaches are one reason why Dr. Ramirez was elected to the National Academy of Medicine, to the board of the Centers for Disease Control, and as president of TAMEST, Texas’ society of national academy members.
“The patient doesn’t live in a bubble,” Dr. Ramirez said. “The physicians are locked down to 15-minute consults. We’re looking at a holistic approach to the patient. We put notes into the medical records so the physician can see what other needs the patient has that influence the ability to be compliant.” Issues include transportation, insurance, medication, childcare, caregiving responsibilities, or unsafe living environments.
Building upon CWHs (also called promotores), who provide general health information and connect the patient with social services and other support mechanisms to help them overcome their challenges, Dr. Ramirez has created the next level up from the CHW: the patient navigator. This person “crosses the line into the health care system” and creates a one-on-one relationship with the patient, Dr. Ramirez said.
Using Delivery System Reform Incentive Payment (DSRIP) funds—a federal program through the Affordable Care Act that rewards health outcomes for low-income, uninsured people—IHPR is working with primary care physicians at UT Health Physicians who were not able to help patients manage their chronic diseases, such as diabetes or depression. The CHWs use home, phone and clinic visits to makes sure these patients can fill their prescriptions, are compliant with their medications, and adhere to diet and exercise regimens. The patient navigators make sure they have transportation to and from their clinic visits, and can be rapidly seen to avoid ER visits.
Rebecca Jones, Ph.D., assistant director of the IHPR, explained, “Leveraging the familiarity of the CHW project, over the past 1½ years, we are getting 30 percent of the patients into depression remission, which the university was not able to do prior to us getting involved. It speaks to the model Dr. Ramirez developed over the years to be able to work with an entirely different patient population.
“We’re not only helping manage their depression symptoms, but we also identify food insecurity, issues with transportation, medical equipment needs and other social service needs. It’s the navigation piece. It speaks volumes in closing the loop in terms of the benefits of CHWs in primary care,” Dr. Jones added.
Dr. Ramirez has reinvented the use of cell phone and social media technologies to emphasize the importance of being healthy to reduce hospitalizations—the value-based model, where reimbursement is based on shared savings. Thus, the goal changes from increasing physician encounters and procedures to enhancing health to decrease procedures and hospitalizations.
In 1992, she launched the first-ever assessment of cancer risk factors among Latinos, which led in 2000 to Redes En Acción, a large national research network to look at similarities and differences in regard to cancer in Latinos. It is part of a $60 million effort by the National Cancer Institute, which funds most of her projects.
Dr. Ramirez, who joined UT Health San Antonio in 2006, also created a network called Salud America!, a national Latino-focused organization funded by the Robert Wood Johnson Foundation that originally focused on childhood obesity but now has more than 250,000 community leaders who focus on promoting system and environmental changes to create health equity and reduce disparities.
“Over the last 25 years, the Latino community has really grown, but a lot of the issues our community confronts are still unknown. For some reason, we have longevity even though we have multiple comorbidities. So that means that our quality of life isn’t the best because of all the comorbidity,” said Dr. Ramirez.
Dr. Ramirez has long worked in tobacco cessation using mass media and community health workers. Physicians at UT Health invite their smoking patients to connect with IHPR’s text-based Quitxt program, which is funded through the Cancer Prevention Research Institute of Texas. Using text messaging and Facebook Messenger, the free service in English or Spanish offers mobile support that is proven to double a person’s odds of quitting smoking for good. It is currently being expanded to include vaping.
With Latinos now the largest minority population in the U.S. at 18 percent, Dr. Ramirez is leading efforts to raise the consciousness of her community through more social media outlets and apps and to spread the concept of credentialed patient navigators to help Latinos navigate the paperwork, transportation issues and follow-up issues of the complex health care system.
“Latinos are a dynamic, rising population, and their health is key to the future of the United States,” Dr. Ramirez said. “We are working to create an environment where everyone has a fair, equitable chance to achieve the best health possible.”