Social determinants of health (SDOH) play a pivotal role in shaping disparities in care and wellness across populations. Addressing these challenges is essential for advancing health equity, ensuring that everyone has the opportunity to achieve optimal health regardless of their background, income, or zip code.
In a busy urban trauma center, where patients face a variety of social determinants of health, it can be hard to identify which issues to tackle first. At Lawrence General Hospital (Lawrence, MA), our patient population faces a variety of socioeconomic, language, chronic health, education, and social challenges.
To improve health equity, we have embraced a data-driven operational philosophy which aims to enhance the patient experience and optimize care delivery. By systematically collecting, analyzing, and interpreting data, it becomes easier to uncover trends and inequities that may otherwise be overlooked.
Evaluating health inequities
The use of data analytics supports Lawrence General’s mission of a more informed, efficient, and patient-centric healthcare model. By following the data available in our EHR, we have identified language and health literacy as primary barriers to achieving equitable outcomes. For example, our clinicians observed disparities of care between English speaking and non-English speaking patients. To help address this, we established a diversity, equity, and inclusion committee to drive improvements through data collection, analysis, and executive leadership. This led to the implementation of a health equity dashboard that provides insight into health inequities and social determinants across our patient population.
While working on these efforts, we conducted a Community Health Needs Assessment in which participants shared their top health concerns. This revealed that we had to account for a number of chronic disease challenges in our patient population, including (but not limited to):
- Obesity: The obesity rates range across our service area, but in Lawrence 33.2% of adults are obese – higher than the statewide rate of 23.3%
- Diabetes: Our providers and residents both expressed concerns about the prevalence of diabetes and obesity within the community. The percent of adults with diabetes varied across the service area, from 6.2% in a surrounding suburb to 11.5% in Lawrence.
- Cardiovascular Health: Survey respondents identified high blood pressure/hypertension as an important issue for themselves and their families or their patients. Quantitative data for the communities in our service area show that hospitalization rates for cardiovascular disease vary greatly across communities. In our service area, cardiovascular disease hospitalizations range from 918.9 hospitalizations per 100,000 population in a surrounding suburb to 2,237.9 hospitalizations per 100,000 population in Lawrence.
After identifying these trends, we developed goals for how to provide care to at-risk patients, specifically those better served in a language other than English and those with low health literacy. This included decreasing readmissions for patients who required an interpreter, implementing targeted community outreach, widespread education efforts targeted toward providers as well as adding multi-lingual health education videos to patient education materials, and developing additional data measuring tools.
Overcoming language barriers
About half of Lawrence General Hospital’s patient population is Hispanic, with 67% of those patients indicating Spanish as their preferred language, 76% of whom indicate the need for an interpreter. Since initiating routine screenings for social determinants of health at our primary care sites, we discovered that 22% of patients screened positive for one or more social determinants of health, and of those who screened positive, 58% said they needed help reading or understanding medical and/or pharmacy information, indicating a health literacy concern.
Additionally, patients who required linguistic support were found to be readmitted at higher rates than their English speaking counterparts. In order to assist with these challenges, we implemented several strategies:
- Rolled out pocket translators to physicians and reeducated clinicians on how to use existing language resources
- Implemented interpreter rounding on patients who indicated a preferred language other than English
- Added special indicators to the EHR for patients requiring an interpreter
- Began developing documentation that will be used to validate that patients received appropriate linguistic support.
Community involvement
One of the most important ways we’ve improved health equity at Lawrence General is by engaging with our community. We stay in tune with our patients by participating in various outreach programs, health fairs, and educational initiatives aimed at promoting health and wellness among residents.
With these efforts, we are determined to gain a clear picture of our patient populations and the issues they are facing. For example, using data collected during community blood pressure screenings, we identified a high incidence of untreated and/or uncontrolled high blood pressure that screening participants were often unaware of, as high blood pressure is often asymptomatic. We now have a van that goes out into the community, 3-5 times a month, to conduct blood pressure screenings and give out free blood pressure monitors. All participants receive a follow-up call from a bilingual (Spanish/English) RN to ensure connection to health insurance and primary care services, and to confirm that the participant knows how to use the blood pressure monitor.
Data is an indispensable tool in the fight for health equity
Leveraging analytics has empowered our staff to understand, address, and mitigate the impact of social determinants of health. We are driving meaningful improvements in patient care and can validate the positive impact of our efforts. Year after year, Lawrence General has seen reduced readmission rates among patients requiring interpreters, decreasing from 10.52% in 2021 to 7.94% in 2024. This is not only important for patients, but also lessens the strain on hospital resources, mitigates physician burnout, and gives time back to physicians to connect with their patients.
Our staff has a passion for caring for each individual patient, but also for their full community. Digital health initiatives such as tracking language, SDOH factors, readmissions, and appointment compliance have helped build a bridge to health equity. We will continue our commitment to improving patient care and health outcomes for the population we serve to ensure no one is left behind.
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