Leveraging Science to Advance Health Equity: A Regional Health Policy Research Center's Approach.

Advancing health equity and reducing disparities through evidence-based policy research requires the expertise, insights, and active participation of various policy stakeholders - particularly those representing vulnerable populations who may be disproportionately affected by such policies. Unfortunately, there are few sustainable settings for these diverse stakeholders to convene, share their knowledge, develop and execute research in a collaborative fashion, and effectively translate evidence-based findings. The development of a health policy-focused center supports the collaborative structure needed to present a unified, multi-disciplinary approach toward informing health policy. The Transdisciplinary Collaborative Center for Health Disparities Research (TCC) at Morehouse School of Medicine (U54MD008173) was funded in 2012 by the National Institute on Minority Health and Health Disparities (NIMHD) as an innovative approach for conducting health policy research and disseminating evidence-based science to diverse stakeholders. This article provides an overview of the research projects, pilot project programs, infrastructure cores, communications, and strategic dissemination activities supported by the TCC.

Explication of a Behavioral Health-Primary Care Integration Learning Collaborative and Its Quality Improvement Implications.

In an effort to tackle fragmented care in the US healthcare delivery system, we explored the use of learning collaborative (LC) to advance integration of behavioral health and primary care as one of the potential solutions to a holistic approach to the delivery of quality healthcare to individuals with physical and mental illness. How a diverse group of primary care and behavioral health providers formed a Community of Practice (CoP) with a common purpose and shared vision to advance integrated care using a LC approach is described. An account of their learning experience, key components of their quality improvement, practice changes, clinical processes, and improved outcomes are explained. This paper aims at describing the history, creative design, processes, roles of the CoP and impact of the LC on the advancement of integrated care practice and quality improvements for further exploration and replications.

The Need to Promote Sexual Health in America: A New Vision for Public Health Action.

Sexual health is considered to be a state of wellness with physical, emotional, mental, and social dimensions. Sexual health can contribute to our overall well-being in each of these dimensions. However, despite the intrinsic importance and positive aspects of sexuality in our lives, the United States presently faces significant challenges related to the sexual health of its citizens, including human immunodeficiency virus, other sexually transmitted infections, viral hepatitis, unintended pregnancies, sexual violence, sexual dysfunction, and cancers in reproductive tracts with serious disparities among the populations affected. In particular, high rates of poverty, income inequality, low educational attainment, stigma, racism, sexism, and homophobia can make it more difficult for some individuals and communities to protect their sexual health. Given that many pressing public health issues in the United States are related to sexual health and that sexual health has been increasingly recognized as an important national health priority, now is the time to energize and focus our efforts toward optimal sexual health of the population. In this paper, we outline the rationale for addressing sexual health as a means to better promote overall health and address sexuality related morbidities. In addition, we present a logic model outlining an approach for advancing sexual health in the United States, as well as a range of action steps for consideration by public health practitioners, researchers, and policymakers.

Promoting Mental Health Equity: The Role of Integrated Care.

People suffering from mental illness experience poor physical health outcomes, including an average life expectancy of 25 years less than the rest of the population. Stigma is a frequent barrier to accessing behavioral health services. Health equity refers to the opportunity for all people to experience optimal health; the social determinants of health can enable or impede health equity. Recommendations from the U.S. government and the World Health Organization support mental health promotion while recognizing barriers that preclude health equity. The United States Preventive Services Task Force recently recommended screening all adults for depression. The Satcher Health Leadership Institute at the Morehouse School of Medicine (SHLI/MSM) is committed to developing leaders who will help to reduce health disparities as the nation moves toward health equity. The SHLI/MSM Integrated Care Leadership Program (ICLP) provides clinical and administrative healthcare professionals with knowledge and training to develop culturally-sensitive integrated care practices. Integrating behavioral health and primary care improves quality of life and lowers health system costs.

HIV Screening Rates among Medicaid Enrollees Diagnosed with Other Sexually Transmitted Infections.

INTRODUCTION: Approximately 20 million new sexually transmitted infections (STIs) are diagnosed yearly in the United States costing the healthcare system an estimated $16 billion in direct medical expenses. The presence of other STIs increases the risk of HIV transmission. The Centers for Disease Control and Prevention (CDC) has long recommended routine HIV screening for individuals with a diagnosed STI. Unfortunately, HIV screening prevalence among STI diagnosed patients are still sub-optimal in many healthcare settings. OBJECTIVE: To determine the proportion of STI-diagnosed persons in the Medicaid population who are screened for HIV, examine correlates of HIV screening, and to suggest critical intervention points to increase HIV screening in this population. METHODS: A retrospective database analysis was conducted to examine the prevalence and correlates of HIV screening among participants. Participant eligibility was restricted to Medicaid enrollees in 29 states with a primary STI diagnosis (chlamydia, gonorrhea, and syphilis) or pelvic inflammatory disease claim in 2009. HIV-positive persons were excluded from the study. Frequencies and descriptive statistics were conducted to characterize the sample in general and by STI diagnosis. Univariate and multivariate logistic regression were performed to estimate unadjusted odds ratios and adjusted odds ratio respectively and the 95% confidence intervals. Multivariate logistic regression models that included the independent variables (race, STI diagnosis, and healthcare setting) and covariates (gender, residential status, age, and state) were analyzed to examine independent associations with HIV screening. RESULTS: About 43% of all STI-diagnosed study participants were screened for HIV. STI-diagnosed persons that were between 20-24 years, female, residing in a large metropolitan area and with a syphilis diagnosis were more likely to be screened for HIV. Participants who received their STI diagnosis in the emergency department were less likely to be screened for HIV than those diagnosed in a physician's office. CONCLUSION: This study showed that HIV screening prevalence among persons diagnosed with an STI are lower than expected based on the CDC's recommendations. These suboptimal HIV screening prevalence present "missed opportunities" for HIV screening in at-risk populations. Measures and incentives to increase HIV screening among all STI-diagnosed persons are vital to the timely identification of HIV infection, linkage to HIV care, and mitigating further HIV transmission.

Improving Quality of Emergency Care Through Integration of Mental Health.

The goal of this study was to better integrate emergency medical and psychiatric care at a large urban public hospital, identify impact on quality improvement metrics, and reduce healthcare cost. A psychiatric fast track service was implemented as a quality improvement initiative. Data on disposition from the emergency department from January 2011 to May 2012 for patients impacted by the pilot were analyzed. 4329 patients from January 2011 to August 2011 (pre-intervention) were compared with 4867 patients from September 2011 to May 2012 (intervention). There was a trend of decline on overall quality metrics of time to triage and time from disposition to discharge. The trend analysis of the psychiatric length of stay and use of restraints showed significant reductions. Integrated emergency care models are evidence-based approach to ensuring that patients with mental health needs receive proper and efficient treatment. Results suggest that this may also improve overall emergency department's throughput.

Reducing Health Disparities and Improving Health Equity in Saint Lucia.

St. Lucia is an island nation in the Eastern Caribbean, with a population of 179,000 people, where chronic health conditions, such as hypertension and diabetes, are significant. The purpose of this pilot study is to create a model for community health education, tracking, and monitoring of these health conditions, research training, and policy interventions in St. Lucia, which may apply to other Caribbean populations, including those in the U.S. This paper reports on phase one of the study, which utilized a mixed method analytic approach. Adult clients at risk for, or diagnosed with, diabetes (n = 157), and health care providers/clinic administrators (n = 42), were recruited from five healthcare facilities in St. Lucia to assess their views on health status, health services, and improving health equity. Preliminary content analyses indicated that patients and providers acknowledge the relatively high prevalence of diabetes and other chronic illnesses, recognize the impact that socioeconomic status has on health outcomes, and desire improved access to healthcare and improvements to healthcare infrastructures. These findings could inform strategies, such as community education and workforce development, which may help improve health outcomes among St. Lucians with chronic health conditions, and inform similar efforts among other selected populations.

Improving Service Coordination and Reducing Mental Health Disparities Through Adoption of Electronic Health Records.

Despite widespread support for removing barriers to the use of electronic health records (EHRs) in behavioral health care, adoption of EHRs in behavioral health settings lags behind adoption in other areas of health care. The authors discuss barriers to use of EHRs among behavioral health care practitioners, suggest solutions to overcome these barriers, and describe the potential benefits of EHRs to reduce behavioral health care disparities. Thoughtful and comprehensive strategies will be needed to design EHR systems that address concerns about policy, practice, costs, and stigma and that protect patients' privacy and confidentiality. However, these goals must not detract from continuing to challenge the notion that behavioral health and general medical health should be treated as separate and distinct. Ultimately, utilization of EHRs among behavioral health care providers will improve the coordination of services and overall patient care, which is essential to reducing mental health disparities.

An Examination of Perceptions in Integrated Care Practice.

Successful integration of behavioral health and primary care services is informed by perceptions of its usefulness to the consumer. An examination of provider, staff and patient perceptions was conducted across five integrated care sites in order to describe and examine perceptions and level of satisfaction with integrated care. A quantitative study was conducted with data collected through surveys administered to 51 patients, 27 support staff, and 11 providers in integrated care settings. Survey responses revealed high levels of satisfaction with integration of primary and behavioral health services. Integrated care can be enhanced by addressing provider competency and confidence concerns through continued education, increased collaboration and utilization of diagnostic tools. This analysis provides evidence to support that successful integration increases access to mental healthcare, which is instrumental in reduction of the mental health treatment gap by scaling up services for mental and substance use disorders among individuals with chronic medical conditions.

Toward culturally centered integrative care for addressing mental health disparities among ethnic minorities.

Despite decades of research, recognition and treatment of mental illness and its comorbidities still remain a significant public health problem in the United States. Ethnic minorities are identified as a population that is vulnerable to mental health disparities and face unique challenges pertaining to mental health care. Psychiatric illness is associated with great physical, emotional, functional, and societal burden. The primary health care setting may be a promising venue for screening, assessment, and treatment of mental illnesses for ethnic minority populations. We propose a comprehensive, innovative, culturally centered integrated care model to address the complexities within the health care system, from the individual level, which includes provider and patient factors, to the system level, which includes practice culture and system functionality issues. Our multidisciplinary investigative team acknowledges the importance of providing culturally tailored integrative health care to holistically concentrate on physical, mental, emotional, and behavioral problems among ethnic minorities in a primary care setting. It is our intention that the proposed model will be useful for health practitioners, contribute to the reduction of mental health disparities, and promote better mental health and well-being for ethnic minority individuals, families, and communities.

The potential for elimination of racial-ethnic disparities in HIV treatment initiation in the Medicaid population among 14 southern states.

OBJECTIVES: The purpose of this study was to explore the racial and ethnic disparities in initiation of antiretroviral treatment (ARV treatment or ART) among HIV-infected Medicaid enrollees 18-64 years of age in 14 southern states which have high prevalence of HIV/AIDS and high racial disparities in HIV treatment access and mortality. METHODS: We used Medicaid claims data from 2005 to 2007 for a retrospective cohort study. We compared frequency variances of HIV treatment uptake among persons of different racial- ethnic groups using univariate and multivariate methods. The unadjusted odds ratio was estimated through multinomial logistic regression. The multinomial logistic regression model was repeated with adjustment for multiple covariates. RESULTS: Of the 23,801 Medicaid enrollees who met criteria for initiation of ARV treatment, only one third (34.6%) received ART consistent with national guideline treatment protocols, and 21.5% received some ARV medication, but with sub-optimal treatment profiles. There was no significant difference in the proportion of people who received ARV treatment between black (35.8%) and non-Hispanic whites (35.7%), but Hispanic/Latino persons (26%) were significantly less likely to receive ARV treatment. CONCLUSIONS: Overall ARV treatment levels for all segments of the population are less than optimal. Among the Medicaid population there are no racial HIV treatment disparities between Black and White persons living with HIV, which suggests the potential relevance of Medicaid to currently uninsured populations, and the potential to achieve similar levels of equality within Medicaid for Hispanic/Latino enrollees and other segments of the Medicaid population.