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Essential Elements

Each component of the Roadmap focuses on specific activities to advance health equity such as diagnosing root causes of health inequities, designing a care delivery transformation, or creating a payment model to support an equity-focused care transformation. The Roadmap’s essential elements— partnering with patients and community-based organizations, obtaining and maintaining stakeholder buy-in, and anticipating data challenges—represent important activities critical to the success for each component of the Roadmap. When organizations do not adequately consider these essential elements, it can delay the work in all aspects of the Roadmap.

Partner with Patients and Community-Based Organizations

Patients and community members experience care differently than clinic staff and providers and often have answers to key health equity questions. Their input is crucial.  Staff at care provider organizations, health plans, and government agencies may be unable to recognize their role in perpetuating inequities. Patients and community members can offer unique and honest feedback on why inequities exist and how best to address them.  Their knowledge and expertise is necessary to identify the most effective care and payment transformation models.

At minimum, patients living with the inequities you want to address should be actively included in focus groups, surveys, or interviews and, ideally, in the creation of the root cause analysis. The ultimate goal should be solidifying an ongoing partnership with patients and communities that reinforces their importance to the organization.  Such partnerships can become one part of a long-term series of actions to establish and strengthen patient and community trust in the organization. They should be fairly compensated for their time and expertise and afforded decision-making authority. 

Partnering with patients also helps ensure that health equity efforts are as culturally appropriate and effective as possible. Staff are not a sufficient proxy for patients. Patients and staff have different requirements, motivations, and expectations for how the care system can and should work for them. For example, staff who are from the same racial group as patients but differ in ethnicity or immigration status may have different concerns and expectations as they relate to which patient-care services are necessary or valued.

People have multiple intersecting identities that influence their lived experience. In the case of those from historically marginalized groups, those intersecting identities can limit the impact of the care transformation.

For instance, the healthcare experiences of People of Color with a disability are quite different from non-Hispanic white people with a disability.  A care transformation that attends to patients with disabilities, then, must consider the experiences of the various individuals within the larger disability community. This logic applies to all patient populations. If a care transformation focuses on people of Asian descent, at the very least, it is necessary to consider globo-regional differences (i.e. East vs. South Asian) in addition to sexuality, disability, and/or whether they are of mixed ancestry. Taking the time to consider which specific demographics will be represented in the care transformation will eliminate unnecessary confusion, uncover blind spots, and create a more tailored, effective initiative.

Obtain and Maintain Stakeholder Buy-in

Buy-in is an important part of establishing and sustaining initiatives to advance health equity. Your team is more likely to succeed if you have the concrete support of all the stakeholders involved.

Part of the Roadmap focuses on creating a culture of equity throughout all participating organizations. With a strong culture of equity, staff across all partner organizations recognize health inequities and take responsibility for addressing them. They pledge to uphold a general commitment and willingness to prioritize equity. But what will stakeholders think about your requests to engage in the work of the Roadmap, and the myriad activities necessary to Implement Your Care Delivery and Payment Transformation? That’s where buy-in becomes important.

Buy-in from everyone—from leadership at each organization to staff, to patients, their family, and community members—at the start of the care transformation process is critical to the success of your health equity activities.

Your team is more likely to succeed in its initiatives if you have the concrete support of all the stakeholders involved. Keep reading for answers to common questions about how buy-in supports a successful initiative.

What is buy-in?

Buy-in is the commitment of interested or affected parties to implement a plan. More than just passive acceptance, buy-in is a commitment demonstrated through action.

Buy-in generally takes the form of a concrete pledge to support the project and help it succeed. Below are examples of what buy-in might look like for three different, but equally important, groups.

Why is buy-in important?

Buy-in from all stakeholders is necessary for a successful, sustainable initiative that evolves with the organization and the changes in the communities it serves. Keep reading for more detail on the impact key stakeholders can have on your initiative.

Staff: Staff input is an important factor in ensuring that your activity will be adopted and properly implemented. Any new activity, care transformation, or payment transformation will affect staff. It’s important to consider who might be affected or involved at each partnering organization, either directly or indirectly. Likewise, it’s essential to determine whose support and assistance you need to ensure the success of your program.
Nearly every team or department of a partnering organization may be involved in some aspects of a complex health equity initiative. Examples of departments and teams include, but are not limited to: legal, information technology, financial, diversity and inclusion, human resources, procurement and contracting, care delivery, risk management, and actuarial.

Patient and Family: Patient and family buy-in is essential to the initiative’s success and will help foster participation in your program.

Community Buy-in: When done right, community partnership and buy-in will build trust. It is extremely rare that a long-standing healthcare organization has an unblemished record within the community. Begin by learning the entire history of your organization and the many roles it has played in the community. Make the effort to learn the positive history as well as the negative actions that might have generated mistrust and grievances. Pay attention to and take seriously reports of racism and other forms of oppression and discrimination made by staff, patients, and/or community members. Show those affected that you take their claims seriously by including them in the creation and implementation of a mutually agreed upon amelioration plan.

Providing resources and support to the community that they deem important, without strings, conditions, or requests for reciprocation is a key component of building authentic partnerships with community members and community-based organizations.

Community stakeholders will be more likely to publicize the program if it addresses their priorities and they trust the organizations involved. In turn, community-based organizations may become more willing to support and sustain the initiative over time as more patients and family members become involved.

A well-designed initiative not only plans for initial implementation challenges, it also anticipates what it will take to keep it running long-term. An initiative designed with sustainability in mind has some key important benefits:

How is staff buy-in obtained?

Staff need to know that in addition to completing their day-to-day tasks, their input will inform the design, implementation, and evaluation of the care transformation. Below find some tips about how to obtain buy-in from staff from all levels of each of the partnering organizations.

Consult everyone who will be affected: Think about which staff members are likely to be impacted by your efforts to advance health equity and consult with all of them. For example, will administration, finance, the larger care team (e.g., reception staff, medical assistants), legal, human resources or other teams need to play a role?

Minimize time burdens: Be respectful of staff time and solicit information in the least burdensome way. For example, rather than asking staff to take time after or before work to submit their ideas, ask for their thoughts at regularly scheduled staff meetings.

Report back to everyone who gave input: It’s important to report back to everyone who gave input so they know how their opinions were considered, what revisions were ultimately adopted, and why. Showing—not simply telling—respondents their efforts are valued will encourage future participation.

Determine strategy by staff groups: Within an organization, different staff may be motivated for different reasons. Pay attention to what leadership, managers, providers, and care team members would consider motivating factors.  

For example: Leadership may be motivated to support an initiative that helps Black middle-aged women control their Type II diabetes because it would help the organization signal that they value the people who live in the communities they serve. Finance administrators may be motivated because it would reduce costs of caring for people with the disease. Care team members may be motivated by the possibility of patients with diabetes avoiding life-altering complications such as amputations, blindness, or kidney failure.

Engage Leadership: AHE has found that leadership is often most responsive to initiatives with the potential for a positive return on investment and those that leverage existing resources. If possible, present data that demonstrate cost savings or a cost-neutral outcome. Either can be a strong argument in support of your equity activity.

It’s important to note that a return on investment is not necessarily measured in revenue. Sufficient return on investment can also be defined by improved quality of care, enhanced perception of the organization by patients and the community, or by meeting a moral imperative to address health inequities.

Care Delivery Teams

Care delivery team members are often concerned with maximizing patient care efficiency. There are strategies that can enhance the care team using existing institutional resources or promote care outside of the clinic. You might be able to shift some responsibilities from physicians to the broader care team like community health workers or patient navigators, or increase the pharmacist’s involvement in patient care. Remember to ask the entire care delivery team for their suggestions on improving care. Doing so will increase the likelihood of buy-in and potentially uncover new ideas and approaches as well as potential issues you may have overlooked.

Identify, Acknowledge and Address Concerns

Team members at all partner organizations may be wary of affecting ongoing activities with the introduction of a new equity initiative. For example, care provider team members may be concerned about patient flow and room availability. Health plan team members may be concerned about the impact of new documentation or how a proposed payment model will align with existing contracts. Staff at governmental organizations may be concerned about how proposed programs may impact their need to remain in line with state and federal regulations.  Openly acknowledge team member concerns, clearly outline how the initiative will mitigate disruption, and continually gather feedback.

Keep Everyone Informed

Improving patient outcomes is a goal of many, if not all, team members. Taking the time to explain your motivations for the ultimate design of the initiative will increase the odds for greater buy-in. Illustrating how the initiative was designed in partnership with team members will go a long way toward gaining and retaining their support.

Obtaining Patient and Family Buy-in

For many equity-focused quality improvement activities, the success of the project relies on the patient’s active role in participating in the initiative and managing their condition.

There are several steps you can take to inspire active patient participation—including providing feedback to improve the intervention.  Below, find several strategies used by AHE partners and grantees to encourage active participation in their program.

Carefully Consider Recruitment Strategies

The South Side Diabetes Project (SSDP) works in practices and communities in the South Side of Chicago to reduce disparities in diabetes care and outcomes. Staff at the project found that having providers recommend patients for diabetes classes was a successful recruitment strategy. The patients were often honored and excited to be nominated by their doctor.

SSDP didn’t simply rely on provider referrals. Realizing that positive—and negative—word-of-mouth could influence participation numbers, they paid special attention to learning what potential participants’ motivations and goals were for joining the program.
They realized that the way potential participants are approached can make a difference and that sometimes, one’s decision to participate can be influenced by other patients.

Speak to What Motivates Patients

Rather than expect potential participants to recognize the inherent value of the program, SSDP took care in touting the program’s benefits in a culturally responsive and relevant manner, emphasizing how it would help participants meet their health goals.

Put the Program Into Context

The Finding Answers grantees at Yale University made sure that when they screened mothers for depression during visits to the pediatrician, that they kept the parents’ concerns at the forefront of the conversation. They encouraged mothers to undergo treatment for the well-being of their children. Their messaging was successful because it appealed to the mothers’ primary concern: their children.

Anticipate Data Challenges

Planning for potential data challenges when designing and implementing your initiative will help your team create an action plan for how to nimbly respond to unforeseen hiccups.

There are three overarching questions to consider:

Asking and answering these questions as early possible will reduce the chances that your team will encounter unanticipated and significant data-related challenges and delays.
Remember to look to the whole team for assistance in data collection and interpretation. End-users often misinterpret data unknowingly. However, team members who enter data into tracking systems as part of their daily work have experience that can help identify inconsistencies in data reports, faulty understanding of the data, or inaccurate assumptions underlying data calculations that are easily overlooked by other team members such as IT staff members and administrators. Thus, it is important to include front-line staff members who originally collected and entered data into data repositories in data use interpretation, and audit activities.

Whose buy-in do you need to sustainably scale up a successful initiative and what data will they require?

This is perhaps the most important question multi-stakeholder teams should consider as they begin to design and plan for their healthcare delivery and payment reform initiatives. In addition to identifying who is instrumental for project implementation, identify the internal and external stakeholders who will make decisions regarding project sustainability.

Ask how these stakeholders at each partner organization would define the initiative’s success in terms of processes and outcomes. Don’t forget to ask who will ultimately determine if the initiative will be sustained for the long-term. Then, ensure that the initiative is collecting the data needed to provide answers to each of those stakeholders based on the definitions of success they provided.

Data Quality

Keep in mind that despite staff training, there may be a lack of consistency in the data collection and reporting procedures as well as how certain data are defined especially between partner organizations. This is especially true if participating health care providers, health plans, and governmental organizations use different electronic health records or data standards.

How will you use that data during varying stages of the initiative?

Using collected data requires an understanding of not only which data is collected and why, but also who requires it, in what format, and when.

An Initiative’s success will depend on stakeholders’ ability to regularly assess the initiative and make updates. Teams should solidify plans to access and share data, including when and how stakeholders will be informed of the initiative’s progress. They can also determine whether:

Make a Data Plan