Continued Elucidation of the Impact of DEIB Efforts in Primary Care

Amelia AuBuchon, PsyD, Postdoctoral Fellow in Behavioral Medicine, Cooper University Health Care; Philip Fizur, PsyD, Assistant Professor of Medicine and Lead Psychologist for Integrated Primary and Specialty Psychological Services - Integrated Primary Care SIG

There is a growing body of literature that reflects the importance or attending to issues of diversity, equity, inclusion, and belonging (DEIB) in every level of primary care from clinician education and recruitment to implementing evidence-based, whole-person health initiatives.  This literature highlights that attending to DEIB issues contributes to the overall health and well-being of communities. As such, in an increasingly diverse society, primary care providers must ensure that DEIB principles are embedded in their research and practices to deliver quality care to all individuals^1-6. In response to this, the Urban Health Institute (UHI) of Cooper University Health Care is dedicated to improving care delivery for underserved populations, particularly Medicaid and Medicare beneficiaries in Camden, by addressing many of the recommendations offered in the extant literature while producing new research examining their outcomes. Recently, a review was conducted to assess the progress of UHI’s care clinics and identify further directions for care and research, specifically relevant to the delivery of behavioral health services.

Diversity

Diversity in primary care refers to the equitable representation of traditionally minoritized individuals among both healthcare providers and patients. Research indicates that having a primary care team comprised of diverse individuals is associated with a better ability to understand and meet the needs of a diverse individuals. Consistent with the recommendations of Eissa² et al. (2022), an EHR review was completed examining the impact of addressing language barriers in implementation of Cognitive Behavioral Therapy for Insomnia (CBTi). Outcomes suggest that, while implementation was broadly successful both through interpretive services and when delivered by a Spanish-speaking clinician, the latter was associated with faster time to recovery from primary insomnia. In informal interviews with both clinicians and patients, this outcome was attributed not only to increased accuracy of language when care was delivered by a Spanish-speaking clinician trained in CBTi vs a medical interpreter, but also by allowing such clinicians to modify the protocol to include cultural adaptations. More formal research will be conducted to better understand this phenomenon.

Equity

Primary care must ensure that all patients have access to the same high-quality services regardless of their personal circumstances by tackling systemic barriers that contribute to health disparities, e.g. socioeconomic factors, geography, and discriminatory practices within the healthcare system. Again, consistent with recommendations from Eissa and colleagues that high-quality behavioral health services in primary care is available to every individual and family in every community, UHI has sought to modify their practices to ensure anyone who walks through the door receives same-day assessment and opportunity for follow-up care. This has meant switching to an open scheduling system that allows our in-person Patient Services Representatives (PSRs) and Medical Assistants (MAs), who are often most attuned to the psychosocial needs of the patient in the moment, to immediately place patients on Behavioral Health Consultant (BHC) schedules. Those without insurance are connected to the clinic’s health coach to begin the process of enrolling regardless of their ability to pay for these services out of pocket. UHI plans to build on extant research to better understand and leverage the importance of allied health professionals such as PSRs, MAs, and health coaches in these processes.

Inclusion

An optimal primary care environment is one where all patients feel respected, valued, and able to participate in their care by actively listening to patients' concerns, respecting their cultural and personal preferences, and involving them in decision-making processes. It also means that all team members feel supported and able to contribute fully. The Behavioral Medicine DEIB committee was developed in 2020 to foster a community of respect for and appreciation of diversity within and beyond the psychology training programs, and this work has begun to expand into the primary care space with trainees and attendings from other professions. Initial outcomes include the development and delivery of a 4-part didactic series on identifying and responding to microaggressions; promoting all team members to complete and reflect on the IAT annually, and discuss how implicit biases may impact our clinical and supervision work; updating recruitment materials to reflect our dedication to diversity, equity, and inclusion; facilitating workshops and assisting with data collection on program climate; and providing presentations on DEIB issues in training and care delivery with other departments, including primary care. Still, Ufomata³ et al. (2020) note the feasibility, acceptability, and efficacy of comprehensive curricula such as their for primary care residents caring for those Identifying as Lesbian, Gay, Bisexual, or Transgender, such a curriculum has not been implemented at UHI. Research examining LGBT care and adapting the content to appreciate the intersection of our patients’ identity as LGBTQ+ as well as those who have experienced trauma within the context of additional ethnic, social, and other identities will be vital to improving the environment of care.

Belonging

Fostering a sense of belonging means ensuring that both patients and providers in primary care feel that they are important members of the healthcare community, which in turn can lead to stronger relationships, improved morale, and better overall health outcomes. Specific targets include creating welcoming physical environment, for patients and promoting professional development opportunities, supportive leadership, and a culture that values diversity and inclusion for providers. While these ideas have been discussed and integrated to some extent historically in the primary care space, the research construct of belonging in this context remains relatively new both on the provider and patient side. As such, future research at UHI will focus on the adaptation of existing measures of belonging to better understand how this construct maps on to outcomes in training and care delivery in primary care and beyond.

References

1. Borgmeyer C. AAFP Well-Being Activities Expand Focus on Leadership AND Deib. Annals of family medicine. 2024;22(2):175-176. doi:10.1370/afm.3109
2. Eissa A, Rowe R, Pinto A, et al. Implementing High-Quality Primary Care Through a Health Equity Lens. Annals of family medicine. 2022;20(2):164-169. doi:10.1370/afm.2785
3. Ufomata E, Eckstrand KL, Spagnoletti C, et al. Comprehensive Curriculum for Internal Medicine Residents on Primary Care of Patients Identifying as Lesbian, Gay, Bisexual, or Transgender. MedEdPORTAL. 2020;16:10875. doi:10.15766/mep_2374-8265.10875
4. Rudisill AC, Eicken MGA, Gupta D, et al. Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care: A Qualitative Study. JAMA network open. 2023;6(11):e2345444. doi:10.1001/jamanetworkopen.2023.45444
5. Rotenstein L, Gitomer R, Landon B. Pursuing Gender Equity by Paying for What Matters in Primary Care. N Engl J Med. 2023;389(3):198-200. doi:10.1056/NEJMp2301282
6. Sandhu S, Liu M, Wadhera RK. Hospitals and Health Equity — Translating Measurement into Action. N Engl J Med. 2022;387(26):2395-2397. doi:10.1056/NEJMp2211648
7. Rybak TM, Modi AC, Mara CA, et al. A Pilot Randomized Trial of an Obesity Prevention Program for High-Risk Infants in Primary Care. J Pediatr Psychol. 2023;48(2):123-133. doi:10.1093/jpepsy/jsac075
8. Snyder JE, Upton RD, Hassett TC, Lee H, Nouri Z, Dill M. Black Representation in the Primary Care Physician Workforce and Its Association With Population Life Expectancy and Mortality Rates in the US. JAMA network open. 2023;6(4):e236687. doi:10.1001/jamanetworkopen.2023.6687