Hello! welcome to learning and using the policy making process to serve minorities communities. My name is Sarahina Cooper Program Manager with the American College of Preventive Medicine, and I will be moderating this webinar session. Take time to introduce yourself, and your organization in the chat. It is a pleasure to be with you all today. This webinar is made possible by the project Improving Minority Position Capacity to Address COVID-19 Disparities. One of our two supplemental awards funded by the CDC COVID-19 Response Supplement. The purpose of Improving Minority Physician Capacity to Address COVID-19 Disparities is to enhance the capacity of physician-led practices to implement COVID-19 prevention, vaccination, testing, and treatment strategies that improve the health of populations disproportionately impacted by the pandemic, racial injustice, and other forms of oppression. For more information, please visit 00:02:20.000 --> 00:02:27.000 acpm.org. Before we begin, I have a few housekeeping notes All attendees are in “Listen-Only Mode.” Please do not put us on hold if you're calling in. We have also enabled “Live Transcript” you may click on the “Live Transcript” button at the bottom of the screen to “Hide Subtitle” or “View Full Transcript.” Also live transcription is being provided by the CDC Accessibility Program. In a moment that link will be provided in the chat box. Please use the chat box, not the Q& A function to submit any questions for the presenters. Questions will be answered during the live Q&A session towards the end of the webinar. This webinar recording and evaluation survey will be available on the ACPM Learning Management System at learn.acpm.org. An evaluation survey link will also be sent out in the chat box towards the end of this webinar and emailed later tonight with access instructions to all the attendees. Completion and submission of the survey are necessary to receive Continuing Medical Education credit. A few disclousures. ACPM supports this webinar through a Cooperative Agreement with the Centers for Disease Control and Prevention Center for State, Tribal, Local and Territorial Support of the U.S. Department of Health and Human Services. The contents are solely the responsibility of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC HHS or the U.S. Government. The content of this presentation is for informational and educational purposes of only. No part of this presentation is specific legal advice, nor a call to advocate for or against any particular policy. ACPM Leadership and staff have reviewed the content of this webinar and respective presenter disclosures per the Accreditation Council for Continuing Medical Education (ACCME)’s Revised Standards of Interest. The content is not related to the products or services of any ineligible company. All relevant financial relationships have been mitigated. I am delighted to introduce today’s presenters, Dr. William Jordan and Kimberly Ramseur. In 2021. Dr. Jordan joined the AMA as Health Equity Policy Director. He is a family and preventive medicine doctor based in New York City. Most recently, he served as Assistant Commissioner for the Bureau of Alcohol and Drug Use Prevention, Care, and Treatment and during COVID-19 as a Clinical Operations Section Chief at the New York City Department of Health and Mental Hygiene. Ms. Ramseur is an experienced health policy and equity professional with a demonstrated history of providing solutions to access to care problems through advocacy and education. She serves as a Senior Policy Analyst within the Center for Health Equity at AM A. Before beginning at AMA, Kimberly worked for various healthcare-related organizations, fervently learning to view healthcare and access to care issues through several lenses. Thank you, Dr. Jordan and Ms. Ramseur. Thank you, Sarafina for that introduction. I will get us started today with our agenda. It's great to be here with all of you. I will just outline that today's event will be in two parts. And there is a separate Zoom link for the second part. The first hour is an open recorded session, focusing on equitably defining problems and analyzing potential policies. Solutions in the last half hour is a closed session for current grantees on policy related communication skills. The learning objectives for the first hour include describing a potential policy solution and finding emerging relevant policies. The learning objective for the last half hour is around storytelling. We'll start with a few slides just to ground us in health equity. This is one of many drawings illustrating the difference between equality and equity. We can see that the two children in this picture seem similar, except they have very different access to resources. In this case apples, the quality gets them the same support or an equal height ladder. But the resources are apples are still out of reach for one of the children. Equity might give them different supports or different size ladders to give them both a chance at reaching apples. A further step toward justice might be to change the structure that determines how accessible the apples are. We're gonna focus on this structural approach today As Sarafina mentioned I'm a family doctor and I know many of us have had this experience of the patient with chronic illness, who has a complex life that makes it hard to stay healthy with our patients. We see losing a job, and then one's home is a devastating personal story from a policy framework. We can see the difference in intergenerational wealth in a form of home ownership in the United States. And the differences between Black and White community. This obviously started going back to our history of slavery and continue through the Jim Crow era with housing segregation, or redlining and forced by Federal policies and programs and and in recent years, even through the pandemic continued through government, rezoning policies and real estate development programs that saw hard-earned homes taken out from under people of color Here we see on the left a map of how social power flows through policy to influence community conditions or social determinants, then drive disparities and health outcomes. We also see different examples of health, equity, policy principles on the right. Both of these examples are grounded and centering the voices of historically minoritized or marginalized groups most impacted. They focus on equitable community investment that fixes systems rather than people and tracks disaggregated demographic data for accountability moving from policy principles to processes. We see here examples from the CDC. On the left, and race forward on the right. Both examples highlight the importance of stakeholder engagement at each step. The race forward model more explicitly. names taking a structural approach considering some systems of oppression like racism in the policy process. In this section we'll focus on equitably defining problems. It should be pretty clear by now that a key ingredient to equitable policy processes is stakeholder engagement engaging those who are most adversely impacted by an issue will help to more accurately name a problem in context and dig into root causes without assigning blame. There are multiple strategies to make equity explicit and defining the problem under consideration. This includes incorporating the framing generated by communities closest to the problem, as well as digging into quantum and qualitative data on disparate impact as outlined by policy. Link on the right are a few examples of sources of data on disparate exposure and outcomes that can help us in defining problems. These include the National Academy for State Health Policy, the Health Equity Tracker. from Satcher Institute, Morehouse, the National Equity Atlas and the County Health Rankings. The framing generated by communities most impacted will often be influenced by intersecting identities. This intersectionality, based policy, analysis, framework, highlights. How none of our lives can be reduced to a single identity, because categories are socially constructed and vary over time and place. We live amid multiple intersecting systems of oppression, with cumulative impacts. Generally an equitable problem definition will include clear root causes, highlight the divisions between what is and what should be, and offer something narrow enough to be actionable. Here are a couple of examples from public sources of sharpening the definition of problems, including child hunger. on the left and the school to prison pipeline on the right. In defining a problem a key tool is asking questions. We already touched on initial questions about who was more impacted, and we would also ask about the scale and timing of the problem. We may also use tools that you're familiar with like the five "whys", Asking "why" repeatedly to get down to the root causes or something called a four skill analysis, factors that are driving change or preserving the status quo. Learning to get at current policies and expenditures that are involved. Revisiting the patient case we introduced at the beginning of the session, and using some of what we've learned over the last few slides is due for two quick activities. For the first activity try generating a question to help better define the problem that this patient is facing, incorporating some of the equity considerations we just reviewed. Take about two minutes and type your draft question in the chat window. We'll go about another minute on this activity that's in the lower left hand corner of the slide. Hoping that people can start entering some sample questions in the chat window about exploring what's going on with this patient and really getting down to the root causes. Thanks. I see from somebody [chat response] "How are you feeling today?" Alright. We'll see if there are any additional questions that people are generating. [chat response] "Given the issues you're facing where would you like us to start working together to fix the issue?". Thanks. So we'll try the next activity? Oh, there's another one, thanks. [chat response] "What are you eating?" [chat response] "Are you able to get your medical get to your medical appointments?" So that's getting a little bit of a sense of what their food situation is like, and also possibly their transportation. And I've got another one in the chat, [chat response] "I'm glad to see you today." "Given what you're experiencing telling me what's going on and where you would like to start?" And another person asked, [chat response] "How are you sleeping on the couch?" And [chat response] "Are you getting the rest you need?" Another person asked, "Are you able to pick up your prescriptions?" I've definitely had patients where they had housing instability, and they were still coming to see me, either, though they moved clear across the city, and it was taking them 2 h each way to get to clinic And so everything was thrown up in the air in terms of what they were able to access, compared to what they are used to and all their supports. So let's try another quick activity. I think Sarafina pasted that activity in in the chat. This is the instructions on the right and we're gonna paste these links in the chat as well. to the County Health Rankings, and then to the National Equity Atlas. I'd like you to take a couple of minutes and on the County Health Rankings link dig down into how healthy is your community and the measures, to change how health outcomes to health factors in under clinical care. Look at preventable hospital stays and look for the County that you're living or working in similarly. And then National Equity Atlas link under economic vitality, I would look at home ownership, and then depending on what you find for your county on one or the other, just please post it in the findings what you see and how the rates compare between people who identify as Black, and people who identify as White in the County. If anybody was able to find preventable hospital stay information, or on our home ownership rates in their County just post it in the chat to share with the group. Thanks, Sarafina. While people are digging into that I'll go to the next slide. Oh, there we go Cook County preventable hospital rate. Black is 76, 52, and White is 37, 63. So you can see almost twice the rate in terms of the disparity. Thanks for that. And as people dig into this data a little bit, you can see I also did Cook County, because that's where the head office for the AMA is. and you can see here that the two in disparity is similar in preventable hospital stays and in home ownership. So we've talked about defining the problem, I think one of the important things to do once you define the problem better is to decide which stakeholders and this is the right time to actually address the problem. This is going to depend on many franging from equitable impact or fallout, and of authentic authenticity of stakeholder engagement and the feasibility with the current result of resources and landscape. Once you're comfortable working with stakeholders on how you've defined the problem and decided also the right time to act, you'll want to find and evaluate potential policy solutions. When starting your policy analysis, you want to save some work by looking first to aggregated resources. The County Health Rankings and National Academy for State Health Policy sites mentioned when we talked about defining the problem, also have policy examples. In addition, there are County declaration examples, and some older examples from PolicyLink that dive into social determinants. When you're thinking about policy solutions you want to start with what already existss nationally and in your own jurisdiction. There may be good policy on the books that are just not implemented or enforced, or you may want to actually update existing policy if you're starting with more of a blank slate. Then you'll want to look for what other jurisdictions have tried, or what other policies have been proposed. There are a number of nonprofit and governmental resources out there about social determinants and health equity policy. Sometimes listed by jurisdiction. I'll note here that the Centers forMmedicare and Medicaid services, or CMS has social determinants of health measures that are voluntary starting in 2023, and then mandatory in 2024. So that's another thing to look out for. In addition, the Joint Commission has required health equity standards, starting in 2023, with additional voluntary standards for advanced status, current posted for public comment. These are three examples of models for assessing health, equity, dimensions of policy. The racial equity, impact assessment from Race Forward, the racial equity and policy framework from the Commonwealth Fund and the intersectionality-based policy analysis. These models are overlapping, but bring unique lenses about resource, investments, disproportionate impact, which voices are centered at which levels, and the approach to addressing intersecting systems of oppression. For example, fiscal considerations will show up differently, whether inadequate and sustainable funding, impacting feasibility where the funding will come from. Whether from reducing funding to other initiatives that have been limited in their benefit, or have been harmful or raising revenue through taxes or other mechanisms. In some special cases it's even possible to calculate what's known as a social return on investment. Returning to our patient case, let's practice some of what we just reviewed. We'll drop a link in the chat for the National Academy for State Health Policy. If you select population, health and then filter by your State and select a topic such as "community health workers" or "social determinants of health" you can look for relevant policies. Take a couple of minutes and type in the chat, the State and topic you searched on, and if there was a relevant policy that you found. Leave just another minute, as people dig into that resource and look for relevant policies in their state. This is one of the better resources for giving you things by specific jurisdiction. Thanks. I see [chat response] a policy about New Jersey Medicaid around maternal health. So while people are digging into that resource we can do a bonus activity. If you've been looking at policies in the past couple of minutes. you can try one of these questions on the right-hand side that come from Race Forward in terms of doing policy analysis and if you wanna try to answer one of them in the chat. I think often with resources like this one, you may not know the answer to some of these questions, like how authentically people most adversely affected and have been engaged in the development of the policy. You may also not, may not be clear from a policy to what to what extent it as it accesses root causes. For example, you may have something that provides a supplemental benefit for people to get a voucher for a cab ride, or something like that for their medical visits, but you may not be addressing the underlying. causes like investment in transit infrastructure in different neighborhoods. We'll keep moving to the next slide. So I'll hand off to my colleague Kimberly. Thank you, Bill. Alright. So Now we're gonna take a look at some examples of different types of policies related to care coordination and health related social needs. So what you see now is just a snapshot of existing AMA policies, it is not an exhaustive list. But a few examples that touch on health related social needs from declaring health as a basic right to expanding access to screening tools for social determinants of health, to encouraging the development of alternative payment models that provide services to improve the health of vulnerable, high-risk populations. You can find the full text to these policies and others by using the links from the slides or from the AMA website and use the PolicyFinder Tool HR 2503 or the Social Determinants Accelerator Act of 2021, which was supported by AMA, was introduced in the House last year along with the Senate version S.3039, and the Act sought to provide local communities with funding and tools to implement solutions, to address social needs by establishing the Social Determinants Accelerator Interagency Council. Aand earlier this year President Biden signed the Consolidated Appropriations Act into law. And parts of this Act was also included, for example, eight million dollars to go to the CDC's Social Determinants of Health pilot program to provide grants to state local, territorial, or tribal jurisdictions. And so here I wanted to provide you with a State example. Texas is one of several States using policy to address social needs. In 2015 the Texas Legislature established the Texas Help Improvement Network or THIN. The purpose of THIN is to catalyze population health improvement, and increase health equity in Texas through a multidisciplinary and multi-institutional partnerships. Another example of the State is the Texas Managed Care Social Determinants of Health Learning Collaborative, which is a partnership with the Texas Association of Health Plans. the Texas Association of Community Health Plans, and the Center for Health Care Strategies. The collaborative seeks to help Medicaid MCOs and Texas strategies to address social needs. And so on this slide. I want to provide you with some resources that you could use to take a closer look at your State's Medicaid Information on Section 1115 waivers. You could also use this as an opportunity to get an idea of efforts being made in other States, or use the first link to go to the Medicaid dot gov website to learn more about Section 1115 Demonstrations in general or other States not listed here. And so these are just some additional nonprofit governmental and resources that provide data and policy information on equity, social determinants of health, and more from the Commonwealth Fund, which you may already be familiar with to HHS and again the links are provided so you don't have to do additional searches. And so I believe there was a specific request for information just to better understand policies that would support the integration of Community Health Workers into the clinical settings. And I wanted to share with you some specific resources that you might find helpful. You may be familiar with, or even members of, some already such as the American Public Health Association or the National Association of Community Health Workers. But each organization is very unique in the services it offers in the communities it seeks to cover. But all can be used to improve overall learning experiences, or to make worthwhile connections. And so I think that was the last slide I'll turn things over to Bill. Thanks, Kimberly. We'll finish out with a quick overview of how health everybody can show up in different parts of the policymaking process. These are examples of how policy can more explicitly address health equity, and redressing legacies of systems of oppression. This thing includes some aspects we've talked about earlier as well as explicit ideas about fairness, distribution of money, opportunity, and power and undoing historical policy-driven harms. The health equity policy approach is supported by legal integrity and the origin of the policies, legal innovation and creative new frameworks and legal intervention. An additional key aspect of equitable policymaking is understand the varying roles. This includes process lead or leads, decisionmakers to champion or adopt policy, community stakeholders to drive and forming and shaping the policy, and government entities who can provide data expertise, logistic support and implementation. Policy can happen, obviously, at multiple levels and in different sites. These offer a variety of possibilities for intervention, but they can also be in tension with each other. Policy generally is made through two processes, legislative and regulatory. The public can influence both processes at the various stages. For example, through bringing attention in the media, participating in public comment periods, bringing lawsuits in the courts, or electing new lawmakers. Policy can be changed through a variety of nested activities, as you can see on the diagram at right. We can do a lot of research, mobilizing education and advocacy around issues and still steer clear of lobbying for a particular policy. I'll note here two things. Federal funds cannot support lobbying. Secondly, if you're interested in lobbying you should seek experience legal counsel for guidance before engaging. There are multiple resources mentioned here where you can get more information. I know that some in the audience are affiliated with Federally Qualified Health Centers. And so organizations like NACHC, National Association of Community Health Centers have some guidance to offer, and there are a variety of other sources that offer more information about Federal and State situations which can vary widely. When you engage with policymakers through education or advocacy regarding issues there are various opportunities to reach out, and a few common tips when you're engaging. As you're probably familiar with there are various ways of doing outreach to your policymakers, whether meeting with them in their office, attending an event writing to them, calling them, writing in the media, so that you'll get their attention, communicating via social media or attending another public event like a town hall meeting. The advocacy tips include different ways that you can engage with your policymaker, and we're gonna talk a little bit more during the storytelling portion in the second part of this session. There are some additional resources that are made available to AMA members and members of State and specialty societies in the Federation of Medicine. You can find your relevant society in a Federation Directory, find it additional tools for individuals in the Physician Grassroots Network and explore model bills through your Federation society. And I'll hand off to Drew to talk more about ACPM resources. Thank you. Please type questions into the chat box. But before we start the Q&A session, please welcome Drew Wallace with ACPM's Communication and Advocacy for a brief announcement. Yeah. so following on Dr. Jordan and Kimberly's presentation, I just wanted to share a quick plug for some ACPM resources that the might help kind of transition into next steps from what you've learned. So you know today talked quite a bit about the policy analysis and policy development process with a focus on a health equity angle. And part of the next step of that is then learning how to communicate those kind of policy solutions to policymakers to your state and local representatives. Transitioning these really complex intersectional issues into a brief three to five minute kind of elevator pitch for them. So ACPM has some upcoming advocacy training dates. These are led by physician advocates who have deep experience in the field. Registration is ongoing. It is first come first serve, so please do register quickly because we try to cap them [registration] at about a maximum of 20 [attendees] each. Because obvioudly you see this kind of training it it requires a lot of interaction and it's a lot more effective when you have time to talk one-on-one. And then I'd also encourage you to, like Dr. Jordan said, look at the AMA Action Center and Advocacy resources. But ACPM also has similar resources that help facilitate outreach to your Congressional representatives. So thank you so much for the time. Thank you, Drew. And we will now start the Q&A session. Thislive Q&A session will be recorded and available for reviewing post webinar. So please submit any questions you may have into the chat box. I'll give a few minutes for folks to submit questions they may have for the presenters today. Again, if you have any questions to ask our presenters regarding any of the information covered today, please submit in the chat box please. Also as a quick reminder, please remember to complete and submit your post evaluation form to receive Continue Medical Education. I will be dropping that link and instructions into chat. Thank you. We do have one question. "Could you give more guidance or insight into where the line is for physicians betweeb advocacy and lobbying, especially when you are also a researcher or part of various health-related association boards. It feels like it's a slippery slope sometimes with multiple competing interest. Thanks for that question. I think this is definitely a common concern. And and the rules of lobbying are really complex. So, as I mentioned, it's good if you work with an organization that has legal counsel to go there first to get specific recommendations for your organization. I think one of the things that I said in the presentation which I I definitely think is true is that you can do a lot of mobilizing, organizing, and research education just bringing attention to the issue and clarifying the issue. All of that is outside of lobbying. Lobbying really requires making a specific request for a particular policy to be put in place or withdrawn. So I think that's probably the best way to think about it in terms of where to draw the line. I think the rules vary, you know, depending on whether you're an individual acting on your own, or whether you're with an organization. Organizations have different rules depending on their tax status with the Federal Government in terms of what kind of how much lobbying they can do and under what funding sources. And then organizations also have different rules depending on the State that they're located in. So it can be complex, but that's why I focus so much on saying that there's a lot of stuff that you can do that's not lobbying. and then, if you're an individual you have a lot of leadway if you have an organization, there are federal rules to look into for nonprofits in terms of how much lobbying you can do and then staples can get more complex because it really varies. I'm happy to clarify if there's something more that you'd like to inquire about. You mentioned some examples. Yeah, I sure. I think. I think if you want to talk about issues that your patients are facing in terms of facing challenges with access to transportation or access to employment or or food insecurity there's a lot of work that you can do in terms of talking to decision makers to really explain to them from the perspective of us as physicians and from the perspective of the patients and to the extent that they've said it was okay to share their stories. So I think that's really one of the most powerful things that we can do and that's that's why, we're going to work on a storytelling exercise in the next portion. So I think all of that is really meaningful. I have done both that kind of educational work like issue oriented with elected officials locally at the State and Federal level. I think if you're developing a relationship then being able to tell those stories and come back to an issue on a regular basis is really important so that if you do choose to do, lobbying and you figured out, you know what you're kind of concerned are around that that when a policy comes up you already have credibility with that decisionmaker because you've developed a relationship over time. Any other questions from participants in the chat. You can also include in a chat. What are some current policy priorities at your own organization? Like, for example, do you know where to go for advocacy or organization education, and any work that you've done in this area this year with other folks on the call? Dr. Jordan, can you describe how you developed a career focusing in advocacy? And for example, building expertise in space as a physician. Yeah, I mean, I would say, atropos of the ACPM I did a second residency after family medicine and for preventive medicine and that was definitely an opportunity for me to get involved in more policy work. One example is, I got involved in a community based participatory research project with one of my mentors in East Harlem during my preventive medicine residency. And worked closely with different community organizations that were serving on the advisory committee for that project, one of them being a Latinx street vendor organization. I ended up working closely with that organization in terms of getting more permits approved for street vendors to sell fruiots and vegetables in food deserts. So that was that was one example. I would say another example that was also during preventive medicine residency. I did a month in Washington, DC. It was classes in the morning at National Cancer Institute around cancer prevention and I had my afternoon's free so I ended up volunteering at a think tank the Institute for America's Future that was very involved and developing the Affordable Care Act proposal and so ended up getting involved in Affordable Care Act very early in terms of policy advocacy, and ended up joining some of my colleagues locally in New York City, who are involved in doing advocacy around that years ago. And so when a labor union would ask, "Oh, is there a doctor that can come to this upcoming rally, because we have like eight speakers and it would be helpful to have a doctor tell a story" so we would field somebody to go and tell stories about what we're seeing in clinic. So I think honestly, a lot of it started through mentorship and through volunteer opportunities and that's how I initially got involved in policy. Thank you. Do you have any advice for younger physician residents may want to assert and get involved. I would say that it's great to you know, to volunteer with local organizations to really find out what their needs are and and support them in the policy work that they're already doing. So I would say that as in terms of a street vendor work that I was involved in. I would say that the other aspect, you know that we've highlighted on this call, is to really plug in to professional organizations. I was active with the local chapter of the American Public Health Association in in New York City. at that time called the Public Health System Association of New York City, and I eventually it was the co-chair of the policy committee for that chapter. And we had a breakfast every year with the chairs of the health committees of the City Council, the State Legislature, and the Commissioners of Health at the City and State level. So that opportunity of volunteering with the local chapter of the professional society. Really allowed me to and connections around policy. And I see there's another question in the chat. Yeah, "At the beginning of the talk there was a great slide used to explain a difference between 'equality' versus 'equity." "Can you talk more about the other parts of that slide about resource, access, and justice?" "Are they not also a part of achieving equity or should they be considered as separate standalone categories?" Yeah I mean, I think I think the definitions can vary in the depictions can be very variable. I think one of the other common formulations that you see in images around this is, you know, people standing on one side of fense, whether they can see over the fence. One of my preferred versions of that is that they're on a hill, and so some of them are like lower on the hill, and some of them are higher on the hill to start with to show that they have different kind of context or resources that they're starting with. And then in one formulation of that, you know they're looking at like a ball game, and they tear down the fence, and then they call that liberation. So I think the line between health equity and justice is is probably fuzzy, so I'd say that part of the diagram is not as well defined as the discussion of the difference between equality and equity. Thank you, Dr. Jordan. I just wanna say thank you, Dr. Jordan and Ms. Ramseur for your time and an excellent session today. And also our AMA partners and CDC funder. As we close out please still feel free to type in the chat your current policy priorities at you organization and what your organization doing currently in areas of advocacy maybe organizing or education for this policy priority. Also, please remember to complete and submit the post evaluation form to receive Continuing Medical Education. I will also provide those instructions again in the chat. You're welcome to include any additional questions you may have for our presenters today. Also reminded to our funded sites, we will break out into different closed all grantee meeting for a communication skills learning and learning policy process work shop.

policy making process

minority communities

health equity

social determinants of health

stakeholders

care coordination

community engagement

advocacy

physicians