Issue:
The COVID-19 pandemic has put a spotlight on the substantial disparities that have existed in health care for many years. According to the Centers for Disease Control and Prevention (CDC), people from racial and ethnic minority groups have an increased risk of getting sick and dying from COVID-19 (see the graphic and the resources section for more information). Inequities in the social determinants of health, such as poverty and access to health care, are barriers that prevent people from minority groups and different ethnicities from receiving safe, equitable health care.1 This is a problem in all settings of care, but the pandemic has revealed some specific instances of inequitable care problems in hospitals, nursing homes and behavioral health care services.2,3
The Joint Commission previously published two Quick Safety newsletters on disparities in health care — the April 2016 issue focused on implicit bias in health care, and the October 2016 issue addressed cognitive bias in health care. In this issue, we focus on actions that organizations can take to identify and address racial and ethnic disparities while removing barriers to providing safe, equitable and quality health care during and after the COVID-19 pandemic.
Requirements and initiatives to address health care disparities
Title VI of the Civil Rights Act of 1964 prohibits discrimination on the “ground of race, color or national origin” in hospitals and other health care organizations that receive federal financial assistance. In July 2020, the U.S. Department of Health and Human Services (HHS) issued a bulletin, “Civil Rights Protections Prohibiting Race, Color and National Origin Discrimination During COVID‐19,” which applies Title VI to the current COVID-19 public health emergency. HHS has provided compliance guidance that covers COVID-19 testing availability, access to intensive care units, ambulance services, staff assignment, bed/room assignment, and home health services, among other services.4
HHS has numerous initiatives to address the disparate impact of COVID-19 on African Americans and other racial and ethnic minorities, including the following:5
- Strengthening data collection and reporting on racial and ethnic minority populations, which is critical to better understanding the impact of the virus on vulnerable populations.5
- Helping states protect vulnerable populations by awarding funds to state and local jurisdictions to support contact tracing, public health surveillance, and testing.5
The Joint Commission has standards promoting health equity, including nondiscrimination; collection of data on race, ethnicity, and preferred language; health literacy and patients learning needs/styles and preferred patient-provider communication. Also, our Health Equity webpage has free resources, including a monograph, “Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals.” Recently, The Joint Commission named Ana Pujols McKee, MD, Chief Medical Officer and Executive Vice President, as our Chief Diversity and Inclusion Officer. Additionally, a Diversity, Equity and Inclusion Steering Council was recently formed to develop a strategy, oversee its implementation, and monitor progress.
Safety actions to consider:
Below are some strategies that both providers and leaders at health care organizations can take to address and decrease barriers from providing equitable care for their patients during the COVID-19 pandemic.
Actions for providers and leaders at health care organizations:
- Proactively collect data to see if and where disparities and inequities in treatment and service delivery take place in your organization. Take action to reduce inequities in care identified in your data.
- Establish robust equity and quality measurements for delivering COVID-19 self-care information and prioritize groups that have persistently been excluded from receiving health information.6
- Use approved encrypted free platforms to communicate with patients beyond traditional phone calls and office visits to help break down access barriers.6
- Use trusted community voices (such as clergy and sports and entertainment stars) to encourage vaccination against COVID-19 to ensure that minority communities are not disproportionately unvaccinated.6
- Train staff on implicit biases. The education and training should include the following: how to identify their implicit biases; understanding of how their biases can affect their decision-making, including decisions about resources; understanding of how their implicit biases can affect the way they communicate with patients and how patients react.7
- Provide medical interpreters for patients of different cultures and ethnicities who have limited English proficiency or who prefer speaking in a language other than English.7
- Engage racial and ethnic minority personnel at your organization in developing and implementing messaging and plans.6
- Develop digital and written resources that appeal to the populations served.6
- Work with health care professional organizations, public health departments, and your communities to reduce cultural barriers to health care.7
- Connect patients with community resources that help older patients and patients with underlying medical conditions to follow their care plans. For example, reminding them to take their medicines, and helping them obtain medical supplies.7
- Promote a trusting relationship by encouraging patients to call and ask questions.7
Actions for providers and caregivers:8
- Identify key community resources, such as food banks or pantries, housing assistance, infection mitigation supplies (e.g., masks, sanitizer).8
- Provide information in the language that your patient speaks, reads, or understands.8
- Increase capacity for care for vulnerable populations (i.e. increase provider, nursing, social service resources).8
- Be sensitive to the fact that many persons of color feel disrespected by health care workers, which augments the sense of distrust.
Resources:
1. Centers for Disease Control and Prevention. Health Equity Considerations and Racial and Ethnic Minority Groups webpage, (accessed Sept. 1, 2020).
2. TP Shippee, O Akosionu, W Ng, et al. COVID-19 Pandemic: Exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging & Social Policy. 2020;32(4-5):323-333, doi.org/10.1080/08959420.2020.1772004.
3. Substance Abuse and Mental Health Services Administration. Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S.
4. Health and Human Services Office for Civil Rights in Action. BULLETIN: Civil Rights Protections Prohibiting Race, Color and National Origin Discrimination During COVID‐19 — Application of Title VI of the Civil Rights Act of 1964. July 20, 2020.
5. Department of Health and Human Services. HHS Fact Sheet: HHS Initiatives to Address Disparate Impact of COVID-19 on African Americans and Other Racial and Ethnic Minorities (accessed Nov. 4, 2020).
6. Lopez L, Hart LH, and Katz MH. Racial and Ethnic Disparities Related to COVID-19. Journal of the American Medical Association. Published online Jan. 22, 2021. doi:10.1001/jama.2020.26443
7. Centers for Disease Control and Prevention. COVID-19 in Racial and Ethnic Minority Groups. Updated June 25, 2020 (accessed Sept. 1, 2020).
8. Society for Maternal Fetal Medicine. “Strategies to Provide Equitable Care During COVID-19” infographic. May 2020 (accessed Nov. 4, 2020).
Other resources:
- The Joint Commission. Implicit bias in health care. Quick Safety, Issue 23, April 2016.
- The Joint Commission. Cognitive biases in health care. Quick Safety, Issue 28, October 2016.
- U.S. Department of Health and Human Services Office of Minority Health. Advancing the Response to COVID-19: Sharing promising programs and practices for racial and ethnic minority communities. A Virtual Symposium. September 2020.
Resources for behavioral health providers:
- National Council for Behavioral Health: Leadership Check-Up Series: Systemic Racism, Health Disparities and COVID-19: Leading Through Complex Trauma with Resilience and Hope
- National Institute of Mental Health: Shareable resources on coping with COVID-19
- Substance Abuse and Mental Health Services Administration: Behavioral Health Equity, Black/African American webpage and Coronavirus (COVID-19) webpage
Note: This is not an all-inclusive list