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C Federal-Level and Other Initiatives to Address Racial and Ethnic Disparities in Healthcare The following list represents a sample of Federal and non-Federal pro- grams, initiatives, and collaborations related to racial/ethnic disparities in healthcare. This list is not intended to represent a comprehensive in- ventory of Federal programming; rather, it presents some examples of efforts intended to reduce and/or eliminate disparities. EXECUTIVE OFFICE OF THE PRESIDENT Office of Management and Budget Guidance on Aggregation and Allocation of Data on Race for Use in Civil Rights Monitoring and Enforcement. Purpose of these guidelines is to: a) establish guidance for agencies that collect or use aggregate data on race, and b) establish guidance for the allocation of multiple race responses for use in civil rights monitoring and enforcement. The guidelines do not mandate the collection of race data, but standardize its collection if agen- cies choose to gather it. DEPARTMENT OF HEALTH AND HUMAN SERVICES HHS-Wide Initiatives Minority HIV/AIDS Initiative. This initiative, in collaboration with the Congressional Black Caucus, seeks to improve the nation’s effectiveness in preventing and treating HIV/AIDS in African American, Hispanic, and other minority communities. This initiative began in 1999 with $156 million and 384

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385 C: FEDERAL-LEVEL AND OTHER INITIATIVES was increased to $251 million in 2000. The funds are distributed in the fol- lowing areas: 1) providing technical assistance and infrastructure support, 2) increasing access to prevention and care, and 3) building stronger linkages to address the needs of specific populations. Grants are provided to commu- nity-based organizations, research institutions, minority-serving colleges and universities, healthcare organizations, and state and local health departments. Agencies involved include Centers for Disease Control and Prevention, Health Resources and Services Administration, Indian Health Services, Na- tional Institutes of Health, Office of Minority Health, Office of Minority Health-Resource Center, Office on Women’s Health, and the Substance Abuse and Mental Health Services Administration. HHS and the American Public Health Association announced in 2000 a partnership to eliminate racial and ethnic health disparities. The part- nership includes a three-phase plan to develop guidelines for collabora- tion to develop a detailed, comprehensive national plan, and to imple- ment the plan by 2002. Office of the Secretary Office of Minority Health Healthy People 2010. A set of health objectives for the nation to achieve over the next decade. The first goal of Healthy People 2010 is to help individuals of all ages increase life expectancy and improve their quality of life. The second goal of Healthy People 2010 is to eliminate health disparities among different segments of the population. Products of the initiative include, for example, the publication A Community Planning Guide Using Healthy People 2010, a guide for building community coali- tions, creating a vision, measuring results, and creating partnerships dedi- cated to improving the health of a community. The Cross Cultural Health Care Program (CCHCP) was created in 1992 to serve as a bridge between communities and healthcare institutions to ensure access to healthcare that is culturally and linguistically appropri- ate. This program facilitates cultural competency training for providers and medical staff, interpreter training for community interpreters and bi- lingual healthcare workers, outreach to underrepresented communities, community-based research, interpreter services, translation services, and publications and videos relating to cross-cultural healthcare. Office for Civil Rights The Office has engaged in a number of efforts related to disparities in care. It has addressed redlining issues (limiting or eliminating services in

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386 UNEQUAL TREATMENT specific geographic areas), conducted compliance review of home health- care agencies nationwide to ascertain compliance with civil rights stat- utes, and investigated how managed care plans establish their service area and how they target their marketing activities. For example, Region II (New York) has developed a self-assessment tool for providers to assist them in ensuring that their facility is able to meet the challenge of servic- ing a diverse population. The New York Regional Office is also investi- gating allegations of racial disparities in the provision of healthcare ser- vices by some healthcare providers in two counties in New York (e.g., poor quality of care for minorities, lack of access to more prominent medi- cal facilities, language barriers to healthcare), and is collecting and ana- lyzing data pertaining to specific healthcare facilities in an effort to gain a better understanding of the root causes of disparities. In addition, Region V (Chicago) has conducted investigations focused on disparities in kid- ney transplant programs. Agency for Healthcare Research and Quality Measures of Quality of Care for Vulnerable Populations. This initiative will develop and test new quality measures for use in the purchase or improvement of healthcare services for priority populations. For example, one such project will develop a quality of care measure for hypertension in a population of Hmong refugees and pilot test the instrument. Assessment of Quality Improvement Strategies in Health Care. A recently funded study will create a partnership of six health providers to evaluate the effectiveness of nurse management compared to usual care for con- gestive heart failure patients in Harlem. Translating Research into Practice (TRIP). Initiated in 1999, this funding is aimed at generating knowledge about approaches that effectively pro- mote the use of empirically derived evidence in clinical settings that will lead to improved healthcare practice and sustained practitioner behavior change. A priority for the FY2000 TRIP initiative is to determine to what extent general strategies need to be modified to improve quality of care for minority populations. Understanding and Eliminating Minority Health Disparities Initiative will support the development of Centers of Excellence that will conduct re- search to provide information on factors that influence quality, outcomes, costs, and access to healthcare for minority populations. Centers for Disease Control and Prevention Racial and Ethnic Approaches to Community Health (REACH 2010). This five-year demonstration project seeks to eliminate disparities in health in

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387 C: FEDERAL-LEVEL AND OTHER INITIATIVES the following priority areas: infant mortality, cervical cancer, cardiovas- cular disease, diabetes, HIV/AIDS, and immunizations. The two-phase project will support community coalitions in the design, implementation, and evaluation of community-driven strategies to eliminate health dis- parities. Phase I is a 12-month planning period during which needs as- sessments and action plans are developed. Phase II is a four-year period during which action plans will be carried out. An evaluation logic model will be used to guide the collection of data. National Program of Cancer Registries. This program provides funding to states/territories to enhance existing registries and create new regis- tries. FY2001 funding will focus on training and technical assistance to improve collecting race and ethnicity data and evaluating the complete- ness and accuracy of data for racial and ethnic minority populations. Alaska Native Colorectal Cancer Education Project is being developed and will involve screening tests and the provision of specific language to Alaska Natives for use with healthcare providers when discussing colorectal cancer. Hispanic Colorectal Cancer Outreach and Education Project is a partner- ship with the National Alliance for Hispanic Health to increase awareness and screening for colorectal cancer. The CDC is also investigating psy- chosocial and cultural influences that impact prevention attitudes, behav- iors, and adherence to screening guidelines among Puerto Ricans and Dominicans. National Comprehensive Cancer Control (CCC) Program seeks to develop coordinated efforts with health agencies to increase the number and qual- ity of cancer programs and to reduce the burden of cancer in minority populations. National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is a 10-year-old program that funds all 50 state health agencies, DC, 12 tribal organizations, and 6 territories to conduct breast and cervical cancer early detection programs. The program works to ensure that women re- ceive screening services, needed follow-up, and assurance that tests are preformed in accordance with current guidelines. National Training Center initiative trains providers serving American- Indian women to enhance cultural sensitivity and client-provider interac- tions. The CDC is also developing a CD-ROM to educate Ohio providers about various cultural perspectives on breast care and interpersonal com- munication with patients. Research on prostate cancer screening behaviors among African-Ameri- can men, in collaboration with Loma Linda University, will examine the relationship between what primary care providers report telling their pa- tients about prostate cancer and how the men perceive the messages. The CDC has proposed the addition of questions on “reactions to race” to the 2002 Behavior Risk Factor Surveillance System. As questions

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388 UNEQUAL TREATMENT regarding the effects of racism on disparities in health status are raised, the CDC has proposed the addition of race questions to the survey in order to begin to measure racism and its impact on health. Centers for Medicare and Medicaid Services Reducing Health Care Disparities National Project. This project focuses on working at the state level to reduce disparities. Its objectives are to improve health status and outcomes in racial/ethnic populations and re- duce disparity between healthcare received by beneficiaries who are mem- bers of a targeted racial and ethnic group and all other beneficiaries living in each state. Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED) ini- tiative involves the awarding of grants that will help understand and ad- dress factors that contribute to ethnic and racial inequities in healthcare. For example, projects involve topics such as racial and ethnic variations in medical interactions, improving the delivery of effective care to minori- ties, and understanding and reducing native elder health disparities. Health Resources and Services Administration Measuring Cultural Competence in Health Care Delivery Settings. This Project in coordination with the Lewin Group seeks to develop a mea- surement model of cultural competence for healthcare delivery settings. The objectives are to advance the conceptualization of measurement of cultural competence in healthcare settings, identify specific indicators and measures that can be used to assess cultural competence in healthcare, and assess the feasibility and practical application of these measures. Products of the project will include: a framework for measuring cultural competence in healthcare settings; a synthesis and assessment of existing measures; and a report recommending domains, indicators, measures, measurement uses, and data sources regarding competence measurement. Community Access Program (CAP). The CAP helps healthcare provid- ers develop integrated, community-wide systems that serve the uninsured and underinsured. CAP grants are designed to increase access to health- care by eliminating fragmented service delivery, improving efficiencies among safety net providers, and by encouraging greater private sector involvement. Currently, CAP grants support 76 communities in urban and rural areas and on tribal lands. A new application competition in the fall of 2001 will support 40 more communities. Partners in the CAP coali- tions include local health departments, public hospitals, community health centers, universities and state governments. The partners use CAP funds to create and expand collaboration in three main areas—coordi-

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389 C: FEDERAL-LEVEL AND OTHER INITIATIVES nated intake and enrollment systems, integrated management informa- tion systems, and referral networks and coordination of services. The agency also will use FY 2001 funds to provide training and technical assis- tance to all CAP grantees and to support a national evaluation of the program. The Provider’s Guide to Quality and Culture serves as a source for health professionals seeking resources on cultural issues within the context of quality of care. The Guide emerged out of the Quality Center of the Bu- reau of Primary Health Care and was developed by Management Sciences for Health, a nonprofit organization focused on the improvement of glo- bal health. The Guide responds to four of the six national aims articulated by the National Institute of Medicine’s (IOM) Crossing the Quality Chasm report (safety, effectiveness, patient-centeredness, and equity). The Oral Health Initiative, an initiative of HRSA and HCFA, seeks to eliminate disparities in access to oral healthcare and improvement of oral health. The goals of the initiative are to: a) integrate dental health activities within the two agencies; b) partner with public agencies and private dental professional educational and advocacy organizations; and c) promote the application of dental science and technology to reduce disparities. Indian Health Service The Indian Health Service has a number of programs in place to im- prove healthcare access and quality, as well as increase community aware- ness of disease prevention and treatment. For example, the Southwest Native American Cardiology Program was developed in 1993. This program was developed to provide direct cardiovascular care to Native Americans at reservation clinics within the Navajo, Phoenix, and Tucson Areas as well as provide tertiary care for complex cardiovascular disease in Tuc- son. The National Diabetes Program was initiated to develop, document, and sustain a public health effort to prevent and control diabetes in Ameri- can Indian and Alaska Native communities. Other programs, such as the Elder Care Initiative, serve to promote the development of high-quality care for American Indian and Alaska Native elders. The activities of the initia- tive are focused on information and referral, technical assistance and edu- cation, and advocacy. This is accomplished in partnership with a variety of tribal, state, federal, and academic programs. National Institutes of Health A trans-NIH working group, consisting of each NIH institute and cen- ter director, was initiated in 1999 to develop a strategic research agenda on

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390 UNEQUAL TREATMENT health disparities. The objectives of the working group are to: develop a five-year Strategic Research Agenda; recruit and train minority investiga- tors to advance community outreach activities; form new and enhance current partnerships with minority and other organizations that have similar goals to close health gaps; define, code, track, analyze, and evalu- ate progress more uniformly across the agency; and enhance public aware- ness. The National Center on Minority Health and Health Disparities (NCMHD) at the National Institutes of Health was established in 2000. The new Cen- ter will conduct and support research, training, dissemination of informa- tion, and other programs about minority health conditions and about populations with health disparities. The goals of the Center are to assist in the development of an integrated cross-discipline national health research agenda; to promote and facilitate the creation of a robust minority health research environment; and to promote, assist, and support research capacity building activities in the minority and medically underserved communities. Substance Abuse and Mental Health Services Administration Community Action Grant Program—Hispanic priority. Awards are made to Hispanic community-based organizations to support the devel- opment and implementation of substance abuse prevention, addictions treatment, and mental health services for Hispanic adults and adolescents. For example, among the new grants is a program that is working toward a specialized dual-diagnosis model for Hispanic/Latino clients with co- occurring mental and addictive disorders. Specialized HIV/AIDS outreach and substance abuse treatment, a grant program to support community-based substance abuse treatment pro- grams targeted to minority populations at risk for HIV/AIDS. SAMHSA developed a pocket guide and desk reference for clinicians, which has been translated into Spanish, to help providers assess and treat substance abuse conditions. Physicians and nurses serving these commu- nities are being trained at regional meetings, an effort coordinated by the Interamerican College of Physician Surgeons. SAMHSA established a multi-disciplinary panel to develop standards of mental healthcare for Latinos. The panel developed a report that includes Standards from the Consumer Perspective, Clinical Guidelines for Provid- ers, and Provider and System Competencies for Training. The standards are being piloted to develop performance indicators and best practices. SAMHSA has made available new funds to help improve access, ad- dictions treatment, and mental health services in racial/ethnic minority communities in order to reduce disparities in services.

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391 C: FEDERAL-LEVEL AND OTHER INITIATIVES American Indian and Alaskan Native Planning Grants provide funds to communities to support the development of local substance abuse treat- ment system plans to deliver integrated substance abuse, mental health services, primary care, and other public health services. Activities of The Special Programs Development Branch have included: the collection of data on access to and quality of mental health services within ethnic and minority communities; working with representatives of consumer, advocacy, professional, and provider organizations serving minority communities to improve mental health treatment; developing guidelines and measures to assist state and local governments in making services and systems of care responsive to diverse cultural needs; and examining the impact of managed care on access, quality, and cost of men- tal health services for ethnic and minority populations. DEPARTMENT OF VETERANS AFFAIRS The Department has instituted several Centers for Excellence in health- care that focus on healthcare issues unique and prevalent in the minority community. For example, the Centers for Excellence in Hepatitis C, Treat- ment and Prevention have been established in California and Florida. The Center has developed culturally sensitive literature on hepatitis C for dis- tribution in minority communities and has been translated into Spanish, Cherokee, and Navajo. The Department has initiated several investigations to examine dis- parities in care in areas including prostate cancer, cardiac procedures, os- teoarthritis care, and delivery of care to American Indians and Hispanic Americans. OTHER PROGRAMS/INITIATIVES TO ADDRESS HEALTHCARE DISPARITIES The Cambridge Health Alliance is a network of three hospitals, the Cam- bridge Public Health Department, community based programs, physician practices, neighborhood health centers, and a managed Medicaid health plan. The communities serviced by the Alliance have large and diverse minority populations, with 26% of residents living below 200% of the federal poverty line. Among the many intergrated services included are multilingual interpreter services, public health, and preventive services.