**Transcript of Cyberseminar**

**Timely Topics of Interest series**

**VHA Office of Health Equity- What is it all about?**

**Presenter: Uche Uchendu, MD**

**November 4, 2013**

This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or visit the website of the Office of Health Equity on the VA intranet at vaww.pdush.med.va.gov/programs/ohe/oheDefault.aspx. Uche S. Uchendu can be reached at uchenna.uchendu2@va.gov

Moderator:I would like to introduce our speaker for today. Today, talking about the Office of Health Equity – pardon me – we do have the Chief Officer at the Office of Health Equity for the Department of Veterans Affairs, Dr. Uche Uchendu. So at this time, I would like to turn it over to you.

Dr. Uchendu:Thank you, Molly. And greetings everyone from the seat of the nation’s capitol in Washington, DC.  It is a pleasure to have this opportunity to introduce to some of you who may not have already heard about the Office of Health Equity or give more information for those who already have that information but needed to know more. And I believe I can advance my slides, Molly.

Moderator:Yes, go ahead. There you go.

Dr. Uchendu:And that is just the intro. Basically, the questions on this seminar is what is it all about, the Office of Health Equity. And I am going to try to come at it from two angles. How is the VA joining the dialogue on health disparities in vulnerable populations and then what actions can each of us take in our areas of influence to move towards attainment of health equity for all people. 

And before I get much further into it, I would like to have a polling done to get an idea of who is in the audience today. So please, if you would use your mouse to select which one applies, what is your primary role in the VA. Student, trainee, or fellow would be the first bullet, clinician is the second, researcher the next, manager or policymaker, and then other. I will pause briefly for that process.

Moderator:Thank you. It does look like the answers have stopped streaming in for the most part if you would like to review them real quick.

Dr. Uchendu:Okay. It looks like we have a good spread. Some are still streaming in but we have a cross section of people from all the various areas so that is good. Thank you, Molly. 

On this initial slide, I am trying to give a global perspective for making the case for health equity. The reference here is made to the Marmot Review, which other people would refer to as Fair Society Healthy Lives. It was a review led by Professor Michael Marmot that was done for the World Health Organization and some of the conclusions made out of that is what I have tried to put in a very few words. It is a whole review in here as far as making the case for why health equity is important. It talks about the fact that benefits of reducing health inequalities are economic, as well as social, and that the cost of health inequalities can be measured in human terms in terms of life lost or years of live that could have been active that were not in terms of disability. Economic terms would be the impact on the economy from lost productivity, from increasing cost of healthcare for those who may have been healthier but are not. And also, the fact that those who are healthy and working are paying for those who are not. And so no matter how you slice it, it does have impact.

And then there have been other documents, also sponsored through World Health Organization, on the global burden of disease. And there has been, in more recent times, dialogue about the possibility of the VA backing a project to look into the Veteran burden of disease. And that will be a topic for another discussion but that is just giving you that background.

Let’s see, moving further. On this, again, this model seems a little bit busy but I would like you to look at it from – The Healthy People 2020 is where this model is taken from. And basically, it talks about the determinants of health. When you look in the center of this, you find attributes like age, sex, race in the middle. But all of these things have an interplay with individual behavior; social, family, and community networks, the conditions in which people live, and then you talk about the broader society. And all of these through the life course would – I am trying to use my arrow – through the life course would impact health outcomes. And health outcomes can be seen in terms of behavioral outcomes, diseases, conditions, injuries, health and wellbeing, and of course, health equity. And monitoring these will inform health interventions, health policies, and health programs that can eventually improve overall health.

Moving on to the next slide, this is again trying to bring that general perspective from a different angle. Again, this is the life course that I mentioned from the previous slide. There are factors from the individual and from the society that do impact health and they can range from anything to political, social, cultural, and so on, at least on this angle. And then over here, again, the issues of geography – and notice this says geography, which would be rural versus urban, and any other aspects that feed into that. So economic status, race, gender, ethnicity – and these are all areas that are subpopulations that disparities can affect. 

And notice here where the health services and system intervention points direction at the arrow on health outcomes and this is where we come in as a health system. Because there are things that we can do as a health system that can impact health outcomes. Arguably, we may not be able to change people’s genes and things of that nature but there are activities within the health system that will have impact on health outcomes, and that is where all of us do come in. 

And moving on to the next one, this again on making the case and giving the bigger perspective on health equity. This will be again a topic for further discussion, which I am privileged to know that the Cyberseminars will be pursuing this in the coming months. But I wanted to highlight here the fact that ACA – the Affordable Care Act – has at least sixty provisions that do impact health equity and health disparity. In the marketplace, the cultural and linguistic appropriate care, the aspect of nondiscrimination, and special provisions that have to do with American Indians. In addition, there is a requirement for community health needs assessment. And on the health safety net, I know that our Office of Policy and Planning are looking at enrollees that are in states that did not opt into Medicaid. Because in those places, the VA will likely become the safety net for veterans who are within that window of not making the traditional Medicaid and not being able to get the benefits of the expanded Medicaid because their state did not opt into that expansion.

And in addition, also, on workforce diversity, even in the VA itself, the population we serve is continuing to evolve. Several years ago, the footprint for women’s health at the VA is not as strong as it has become in more recent years and affects that in many other angles, as well. The importance of cultural competency and having people be culturally aware of the populations they treat and the impact that could have on the various decisions that we make. And I will come back to that in a future slide.

And then just a couple more things I wanted to highlight on this slide is the medical home – that is the term for the patients at that medical home, which in the VA, we call it a patient aligned care team. And in addition also, I would like to point out the PCORI, which is the Patient Centered Outcomes Research Institute. And on that, actually, the Principal Deputy Under Secretary for Health, Dr. Jesse, served on the PCORI, as well.

And then one more thing here will be the data standard for race and ethnicity. Those of you who have done work in this area will agree that there has been a question mark about the collection of the data and whether the data is accurate to inform all the decisions that sometimes come out of it.

And lastly on this section that talks about public health, the diseases listed here, it is not surprising that the number two cause of death in the United States is cancer. The number seven is diabetes. And so it makes it imperative that we pay attention to these aspects. And like I said, there will be an opportunity to discuss this further in the future.

And so finally, I wanted to tie into the National Partnership for Action to End Health Disparities. This was a partnership of over two thousand various partners that came together of Health and Human Services, Office of Minority Health to mobilize a nationwide and comprehensive community driven approach to tackling health equity. And the mission was the coordination of partners, leaders, and stakeholders committed to action to be able to impact health disparities. And the VA made a commitment with NPA as one of the federal partners, which leads me to the next slide in which I give you the information regarding VA.

The Veterans Health Administration provides a vision for establishing our office was to provide individualized healthcare to every veteran in a way that eliminates disparate health outcomes and assures health equity. And it is not surprising then that the Office of Health Equity is intended to champion the advancement of health equity and reduction of health disparities.

I also wanted to highlight here the fact that it is not just an office was established but also the place that it is taking in the VHA strategic plan. The VHA strategic plan has three overarching goals and each of the goals has multiple objectives under the goals. And I am going to concentrate on telling you about goal number one in order to make the linkage that I am trying to create here. Goal number one talks about providing veterans personalized, proactive, patient driven healthcare. And the objective in question on that goal number one that I wanted to bring to your attention is the quality and equity, which reads – as you can see on your screen – veterans will receive timely, high quality, personalized, safe, effective, and equitable healthcare irrespective of geography, gender, race, age, culture, or sexual orientation. And I will come back to these populations in another slide that will give you a little more perspective on it. But the intention of bringing this into this dialogue here is to underscore the fact that having an item on the VHA strategic plan means that it is required that we weave it into discussions at all levels of policy, decision making, resource allocation, practice, performance, research agenda, and so on and so forth. And here was just to highlight that the NLC committee that has oversight of the VHA strategic plan goal one objective E is the Healthcare Delivery Committee and the Healthcare Quality and Value Committee, as well.

And moving on, I wanted to show you again, the topic today was what is Office of Health Equity all about. This is our organizational structure. The Office of Health Equity reports directly to the Principal Deputy Under Secretary for Health. And we are eight people strong with three of us located in Washington, DC, and my other team members are at various parts in the field. And when I come to the section on our projects and so on, I will be able to tell you a little more about the members on the team. And I think on the next slide, we just felt the need to share this moment. We had a meeting in DC in June. Since all of us are  not here, we had a strategic planning meeting in DC in June of this year. And Dr. Petzel, whom I am sure you can identify in the picture, who is the Under Secretary for Health for the VHA was gracious enough to stop by and share his thoughts with us about the direction the office needed to be moving in VHA and dialogue about health equity. And we had the picture moment also to document that. 

Here, this is again giving you where we fit in the organizational structure. Office of  Health Equity is 10A6 – trying to drag my arrow but it is not coming. Okay, there we go. 10A6 because like I showed on the previous slide, the Principal Deputy Under Secretary For Health is where we align and this takes you down to here. We are one of the offices that reports there so our mail code is 10A6. The rest of the chart is for your reading pleasure at a later time.

And now I move into definitions. It is one of the things I had to do early in my role in this position. And if you have heard it before, I apologize ahead of time. But I think it is important for us to have an understanding of this as we move forward. Health equity is attainment of the highest level of health for all people. And I underlined sentencing here for specific reasons – “valuing everyone equally,” “efforts to address avoidable inequalities.” And if we do not know and we do not do anything about it, it is not as bad as we know and we still let the inequities continue. Historical and contemporary injustices and the elimination of health and healthcare disparities. And again, I will come back to this definition a couple more times before the end of this presentation. But I think it is important for people to understand these definitions.

And so on the next slide, these are the four populations that we refer to when we talk about vulnerable populations. And a health disparity is a particular type of health difference that is closely linked with social or economic disadvantage. And when we talk about social or economic disadvantage, these areas will represent people who have systematically experienced greater social and/or economic obstacles to health and/or a clean environment by race or ethnic group, gender, age, geography, religion, socioeconomic status. And the area that people do not often tend to notice is disability, as well. And of course, under disability could be cognitive, sensory, or physical, and as well – yeah, physical is on there, as well, and then mental health and sexual orientation. And this last bullet is one of my favorites – other characteristics historically linked to discrimination or exclusion. It reminds me that the scope of our office is not completely defined yet and will continue to grow, depending.

And on the next slide, I wanted to emphasize the fact that not all health differences amount to a health disparity. A subset of differences linked with social disadvantage, that is when it becomes a disparity. And overall, you can also approach it from the angle of adverse health in a social disadvantaged or vulnerable group. So every time there is a difference, it is not necessarily a disparity. It is if the difference is linked to social disadvantage or any of the groups that were previously mentioned. Then it becomes an issue for that consideration in that regard.

And I think that takes me to the next question that would encourage each of you to pick up your mouse and participate in this dialogue. And the question is which of the following veterans is likely to have a health disparity? You can select all that apply. An African American male who served in Vietnam and lives in Hope, Arkansas; a transgender white veteran with PTSD who lives in Iowa City, Iowa; a Hispanic female veteran with HIV who lives in Houston, Texas; a sixty-year-old unemployed veteran who sleeps on the steps of the Capitol in DC; and a Native American veteran who lives in Winnemucca, Nevada. I will wait for Molly to tally the poll.

Moderator:Excellent, thank you. It looks like we have virtually identical responses – anywhere from seventy-seven to eighty percent of all of our attendees have clicked each of the responses. So spread evenly across the board, thank you.

Dr. Uchendu:Thank you, Molly, and thank you everyone for participating. I can tell you that every one of you answered correctly. Because every one of the scenarios describe represents a vulnerable veteran. And I will roll by it very quickly. On the very first one, the race is an issue there and rural location is an issue. And one of the things that is not on this slide I showed you previous in vulnerable populations would be military errors. Because many of you who are in clinical practice would agree that Vietnam era vets, in this particular situation, Agent Orange and some of those other things will come up in that regard. And when you go to other eras of veterans, there are also specific things in the Gulf and so on and so forth. And so that in itself is actually a vulnerability. 

The item B covers sexual orientation, mental health, and rural health. Item C covers race, gender, and HIV. I wanted to highlight here, it would qualify under vulnerability under physical conditions. And then item D is mostly socioeconomic. I did not want to say clearly but obviously, this veteran appears to be homeless and homelessness is a vulnerability. And in addition, the last one has race, as well as location. And in that particular location in Winnemucca, Nevada, it is actually beyond rural. It is considered frontier for those of you who are familiar with terms around rurality in the VA. So thank you again for your participation.

And then moving on, I wanted to share this cartoon, which talks about the poor getting poorer but with the rich getting richer, it all averages out in the long run. Again, I wanted to highlight here the problem with averages because obviously, the poor are getting poorer and the rich are getting richer. There are people who are not doing so well but the average looks good. And with that, I wanted to lead into if we talk about the average population health being a certain way. It does not mean that the various populations are getting what the need out of that health system or getting health outcomes that are desirable.

And therefore on the next slide, I wanted also to share a couple of quote, which I believe speak for themselves. But I wanted to highlight here the difference in time. The first quote was from Martin Luther King, Jr. back in 1966. And it is interesting that you find from what 2012 when the second quote from the Secretary for HHS, Kathleen Sebelius. We still have not found solutions, which is why she is saying, “It is time to refocus, reinforce, and repeat the message that health disparities exist and that health and equity benefits everyone.” And that is so many years later after Martin Luther King talks about the fact that, “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” And we are still having that dialogue and we are nowhere near the end.

I wanted to again follow up on the averages that I mentioned earlier. Raising the bar by eliminating the disadvantaged outliers. Many of us are very familiar with the term performance measure, which we track at various facilities for various items. And the question that I wanted to raise here, and the measures we track, range anywhere from, you know, diabetic indicators, hypertension, cancer screening, flu shots, preventive care, depression screen, and so on. What if the percent on target is broken down by age, gender, race, ethnicity, geography, sexual orientation, and all of those pieces that we mentioned in the slide that had the vulnerable population. Would you facility still meet the measure for all populations? If the answer is no, then there needs to be something  that can be done about it. And the other angle I wanted to point out here is that sometimes – and many of you may have experienced this in breaking down some of the performance measures by gender, which was championed by the Office of Women’s Health in the last couple of years. And you find out that they have LDL or hypertension and some of the other items that were picked up were not quite the same in males versus females. And by doing targeted efforts to the certain population, you were able to list the bar on that particular population and therefore, in so doing, moved the general average even further up.

I now would like to give you an overview of the mission of our office. I think you probably have an idea of it at this point. Champion efforts to address health disparities through education, training, communication, information. Coordinate programs, projects, initiatives that address health disparities and equity in order to bring synergy and break down silos within the organization. For this piece, I said to my boss on my first week on the job, I said, “It sounds like I am going to be in everybody’s business.” 

Represent VHA and serve as a liaison to other government and nongovernmental organizations who are working to achieve health equity. As you can see from the initial slides, there is a global approach towards health equity and there are bits and pieces of that that we own as an organization and can do something about. And also, can learn from the bigger global aspect of work that is going on in this regard. The VA, of course, prides itself on being a leader in a lot of things – electronic health records among others – and we would hope that at some point it will also be ahead of the curve in the journey towards health equity.

And finally, we do not want to reinvent the wheel. We hope to capitalize on existing networks. Minority veteran coordinators, women’s health program managers, OEF/OIF, special populations, homeless coordinators, among others. And many offices who are already doing some activities that do impact health equity in moving the dialogue on health equity forward.

The goals and functions of our office are on these key areas – leadership, awareness, health outcomes, diversity and cultural competence of the workforce, and data, research, and evaluation. And again, this is set on the five-goal framework of the National Partnership for Action Stakeholder Strategy for Achieving Health Equity that I had mentioned earlier on the NPA. And as I also showed, some of these are linked with some of the provisions in the Affordable Care Act. 

And now going to each one in a quick summary, if you will, to expand a little bit. On leadership, we hope to broaden the ability of VA to address health inequities in a lot of ways – through our operations, policies, oversights, research – we would like to tackle it from every angle. And leadership, on the one hand, is already stepping out in that direction by including it in the VHA strategic plan. 

Creating awareness. You are part of that effort today, having dialed into this call to find out more about this and hopefully what you can begin to do in your areas in order to other coordinated efforts that will be coming down the road. Being able to understand the fact that health equity is everyone’s problem, not necessarily the people who are the disadvantaged population.

Health outcomes improve health and health outcomes on veteran subpopulations. I think I gave an example of that earlier with the women. If you duplicate that in many other subpopulations, you will be able to lift the bar. We will eventually see a migration to what everybody becoming even much more healthy than they currently are.

Diversity and cultural competence of the workforce is also one of our goals and functions. The population of the United States is changing. The population of the VA is changing and it is important that people understand the diversity of those cultures and how they impact the decisions that people might make with their health. If you were able to see the announcement that went out last week reminding people about this particular cyber seminar, there was an attached video on related resources where Dr. Said Ibrahim had discussed the finding of the Center for Health Equity Research and Promotion on the work that they did regarding knee and hip replacement and the racial differences that were found. And some of the conclusions were where that certain racial minorities did not get knee and hip replacements because they did not know enough about them. There was not a brother, a sister, a cousin, or anyone in their communities who had been through it so it seemed more of a rocket science approach than to others who had had those experiences and were more likely to make a decision to get hip replacement. And that is not the whole study, that is just the angle of it that I wanted to highlight about how important cultural competency is. And I encourage you, if you did not see that video, I think it is less than a seven-minute click. I think it will be a good idea to look at that, as well. It helps put a perspective on this.

Data, research, evaluation. Again, even though I used the work that CHERP did under the aspect of cultural competency, it tells you how interrelated all of these data, being able to mine that data and guide research in directions that can help us answer the questions about health equity. Help us figure out solutions, and in addition, implement those solutions in the major aspects of being able to move the dialogue forward on health equity. And that is the last of the five goals and functions which the Office of Health Equity is currently set up that I wanted to share with you in this segment. 

The expected deliverables out of our office, an integrative VHA Health Equity Action Plan, which I will tell you a little bit more about in the next couple of slide – in some slides coming on before the end of this presentation. Comprehensive Health Equity Communication Plan, which will tie right in along with the action plan. And then analyses using process, outcomes, satisfaction metrics including the CHERP and any other modalities that we already have out there that we use to track progress and cast an equity lens on them to have a better understanding of the approaches that would make sense in moving us forward toward health equity. And of course, a multifaceted cultural competency training program. 

This is again an opportunity for you to pick up your mouse. I would like to get your answers to the following questions. The five-goal framework of the NPA National Stakeholder Strategy for Achieving Health Equity includes all of the following except Affordable Care Act, awareness, health outcomes, diversity and cultural competency of the workforce, data, research, and evaluation. Please log in your answers.

Moderator:Thank you. We do have answers still streaming in so we will give people a few more seconds to make their choice. We have quite a wide spread this time. So roughly, it looks like about eighty-five percent of our audience chooses a; the Affordable Care Act. And it looks like five percent selected b; awareness. Roughly two percent each selected health outcomes and data research and evaluation. And then three percent chose diversity and cultural competency of the workforce. Thank you for those replies.

Dr. Uchendu:Thank you everyone again for participating. If you notice, it said “all of the following except.” And the majority did carry the vote on this one. One of the areas that was not included was the Affordable Care Act. There is – and I know from the dialogue I had earlier, it might be a little confusing. Affordable Care Act has portions of it that speak to health disparity but the five-goal framework of the NPA does not include Affordable Care Act. The missing fifth goal there would be leadership and the same five-goal framework is the five-goal framework that the Office of Health Equity is there to perform. So thank you so much for participating again.

And then I wanted to tell you a little bit more about the Health Equity Coalition. It was established by the Principal Deputy Under Secretary for Health with a memo on March 21 of this year. And I am the current Chair of the Coalition. In my position, I am Chief Officer of the Office of Health Equity and the Coalition is charged with the following, assuring that there is a comprehensive and aligned approach across VHA by address health equity and ensuring the availability of necessary resources and ongoing assessment of the impact. Sorry, I think I went a little too fast there. The rest of the charge includes maintaining a professional connection with OHE, advise and assist in the Office of Health Equity’s development of the action plan, which I will tell you a little bit more about. And commit appropriate organizational resources to be able to implement the contents of the plan, set milestones, and make sure that the actions that are put in place are working in moving us towards health equity and provide necessary support through coordinated systemwide efforts. And of course, engage as appropriate outside of VHA to move this mission forward.

The members of the Coalition are listed here. I would not be reading them aloud for you but I included them in this presentation for completeness. But as you can notice, they are strategically selected to make sure that various aspects of function within VHA is accounted for in addition to people who can actually do something about health equity. And that includes 10N, the Chief Medical Officer representation, Network Director, Office of Nursing, and so on and so forth.

This is the last slide on the Coalition. Started meeting on the thirtieth of May of this year and just like many of you are wondering when you look at the rest of the list of the vulnerable population, this seems like a big apple to chew on, a huge elephant. And you wonder where do you begin to nibble at it. And so the agreement was that we would prioritize over time. We will start with what we know and then begin to move into what we do not. And we agreed to meet monthly until we delivered a health equity action plan and we have just crossed that in the month of September with a draft first of a health equity action plan. I am not going to go into the plan with you on this presentation because we will have a separate comeback in the future through this medium and others to share that in detail after it has been ratified. But I can tell you that it is set on the same five-goal framework that you just answered a question about, and it is aligned with the VHA Strategic Plan Goal 1 objective E. So it is not going to be anything that you are not already aware of to some extent. But it will come with an opportunity also for people to come up with their ideas about how to move this equity journey forward. And the hope is also to fit in some activities that are already going on as you will see with one of the projects that I am going to illustrate before the end of this presentation.

Moving on, this slide will be in flux so it is not going to be etched in stone and we will modify as we go along. And there will be opportunities for bigger sites to adapt to the sites.

The next couple of slides will give you an overview of some of the projects that the Office of Health Equity has been involved with. I think we have talked enough about Health Equity Coalition. As I mentioned here about the VHA Strategic Plan goal 1e, which has been under development and the sections go through NLC. We will come back to you with some more activities coming out of that.

One of the projects I promised to mention to you is a Clinical Look at Unconscious Bias. It was a project that was started in response to inquiries from the advisory committee for the Center for Minority Veterans in 2012. It is a project that Office of Health Equity is doing in collaboration with the Center for Health Equity Research and Promotion. And the facilities who have participated so far in this pilot are Houston VA, Martinsburg VA, and Pittsburgh VA. And it is being done as a pilot and I think I have one more slide that will give you a little more information about it and it will be concluded in FY14. The information from that will inform some future decisions in this regard. 

The Healthcare Equality Index was done over the last year. The results were released in June and my office was in the forefront of leading that charge. And we are glad to remind everyone that ninety-two VA facilities made Leader status out of the one twenty-one that participated. I will have a few more words on that in a future slide.

And then creating awareness about our office. You are part of that effort today and I thank you for tuning in to hear what is going on with the Office of Health Equity and what that means for VHA in moving towards elimination of health disparities. 

And we have also been actively involved in the Federal Interagency Health Equity Team. If you recall, one of our goals is to reach through known governmental agencies. And the bias is actively the piece of HHS that is continuing the work and recommendations of the National Partnership for Action, which we mentioned earlier. And a couple of people in my office are also active on sub-work groups that are on the Federal Interagency Health Equity Team.

Okay, I am going to pause here for one more audience poll by Molly. And Molly, okay, now we have...

Moderator:Sorry, just give me one second here.

Dr. Uchendu:Okay. While Molly is trying to load the right question – there you go. Have you seen the Office of Health Equity Call For Papers for VA Health Equity *American Journal of Public Health* Supplement? Yes, no, maybe, do not know, or perhaps what is this.

Moderator:Thank you. It looks like the answers are streaming in so we will give people a little more time to respond to the question. Okay, it looks like we have about one-third have responded yes, just under two-thirds responded no, and about six percent said what is that? Thank you to our attendees.

Dr. Uchendu:Thank you, everyone. That was trying to see how far marketing or information push on that particular piece had gone. And so I am glad you are on this call if you are within the two-thirds who have not heard about it or those who are wondering what it is. And it would speak for itself typically. Okay, you have to wait for the next couple of slides and I will give you the details of that. Sorry about that.

This is the Healthcare Equality Index that I mentioned earlier. The VA actually hosted the announcement of VA grounds at A10 Vermont because among all the healthcare facilities that participated, VA had the best showing. And actually, the VA was the reason that the human rights campaign that usually organizes the HEI – and this is the Director, Ms. Shane Snowdon, said the VA was the reason they made a showing in all fifty states because of the expanse of our coverage and the level of participation from VA. So needless to say, that was successful across the board.

And on this – okay, I will finish the projects that are going on within the office of Health Equity and then I will show you the flyer for the call for the papers for those of you who had not heard about it. There was a Military Cultural Awareness Workgroup that was chaired by Lisa Red, who is one of the staff within my office. And I wanted to put a plug in here to ask have you seen the TMS training for military cultural awareness. It seems odd that we treat veterans and sometimes people are not very much aware of the military culture that might impact some of the actual decisions and so on that the population we serve might take. So if you have not seen that, go do that search in TMS and you will find it. And also, I wanted to mention here that Office of Academic Affiliations has on their website a template for military history taking – yeah, military history taking that you might find very useful, as well.

Also, within our office, is exploratory work going on on health outcomes and issues on LGBT; specifically transgender, which Dr. George Brown and Dr. Kenneth Jones are working on. And again, that would be information the will come later when there is more to report on it.

And then we have collaboration efforts that are going on with Patient Care Services LGBT coordinators. If you are not aware, Dr. Michael Kauth and Dr. Jillian Shipherd are National LGBT coordinators and have done a lot of work with regards to not just increasing the awareness but also increasing the comfort level of clinicians who are treating LGBT veterans. I know they are in the process of setting up some cultural patient teams and so on and I am sure there will be a forum for them to share that information, as well. Some staff in my office have also partnered with them in developing some of the materials that are available, also, including the TMS.

Collaboration with researchers and data analysts. You know, one of the things Dr. Petzel said in my early days in this role was the VA has a lot of data, let’s do something with it. And so we did convene here in DC with several people with recommendations from Office of Research and Development and also, some expert data analysts within the VA to discuss how we can make the most of the data we have to serve the purposes we needed to in terms of moving the dialogue forward on health equity. And a lot of input and ideas came out of that and a lot of collaboration opportunities, and we are continuing to follow through. 

Also, the Office of Health Equity nominated a topic for Evidence Synthesis Program and we are glad to say that the Durham ESP Center has been assigned that topic and they are working with us and we are extending to include the Office of Mental Health and Primary Care, as well, in moving that project forward. 

And then finally, the *American Journal of Public Health* Supplement on VA Health Equity that some of you have not heard about. If you have not seen the flyer, it is on the very next slide. I will not read it to you but I encourage you to please look at it and see if you or anyone you know are in a position to make a submission. We welcome that input. Additionally, it will be found on the *American Journal of Public Health*website. Also, within VA bylaws, you can find the slide on the homepage of the VA Office of Health Equity and I have that link at the end of this slide.

I was going to tell you just a little bit more about the clinical look at Unconscious Bias project, which is happening in Martinsburg, West Virginia, and Houston. The project was PACT teams again following a plan of trying to fit into processes that were already in place without having to reinvent the wheel. And interactive cultural competency training was incorporated into some of the teams to be able to – And this project is going to be able to access the feasibility and acceptability of the program for being able to implement on a wider scale. And when the results are in, we will be able to have further dialogue about that. And like I mentioned earlier, our business partner is CHERP for that project.

And so that brings me to the last part of the dialogue with you today. What actions can each of us take in our areas of influence to move towards health equity for all people? And in this particular piece, I wanted to again go back to the VHA Strategic Plan, which go 1 objective e has equity in it. And the strategy that my office has developed to move this equity dialogue forward is VHA will develop and understanding of where health and health inequities exist. Identify the factors that contribute and then intervene to eliminate inequities. And the statement beneath is from the performance plan that has been approved for use within VHA and encouraging, as people look at their subpopulations, this will be a good way to hold accountable people who work in sections that can impact health equity. Demonstrate understanding of where health and healthcare inequity exists and address the disparities. And again, it is not expected to pay off the moment you start addressing them but at least you have set the wheels in motion. And I think the reference on the bottom was supposed to be for the next slide. I am sorry it got on this one instead.

And moving on, I wanted to reference the work that was done by VA’s own Amy Kilbourne and others, including referring to a conceptual framework by addressing health equity. Again, it describes three steps, which I will show again in one more slide to hopefully help drive it home. Detecting, understanding, and reducing. I think hopefully, on the course of this dialogue, I have been able to help you define health disparities, help you define vulnerable populations. And then the next step becomes measuring the disparities in these vulnerable populations. Identifying what is causing those disparities and then being able to do something about it with intervention and then evaluate the intervention to see if it works and if it does, go through disseminating. And then adapt quality changes that need to happen to move this dialogue even further.

And on this slide, this is just giving you the same thing in a slightly different conceptual approach. First generation, second, and third. For those of you who are familiar with those terms, again, it talks about the same thing – finding it, explaining it, and trying to provide solutions.

On the next slide, this I include – again, for benefit of those who may not already have this information – health disparities research could be basic, applied, clinical, social, or behavioral. And it looks at the various areas that are underlined there – overall rate of disease incidence, prevalence, morbidity, survival rate in a population, and it could be on an individual and subpopulation basis. It also includes the causes of those disparities and methods to identify, prevent, and do something about them. Again, it would not do as much good if we find those and we do not do anything valuable with it. 

And this is another way of looking at it, and I encourage you in this particular trajectory, if you move Race and replace that with Gender or replace it with Sexual Orientation or replace it with geography or replace it with any of those vulnerabilities which I mentioned in previous slides. The trajectory will still be the same. You detect it, you understand it, you provide solutions, and you take further action. And the solution, also probably comes in the form of research. Being able to transform research into action becomes important. And again, everything does not have to be researched. It could also be QI projects that are transformed into action.

Population Health Research. Again, this is another one for completeness – examines the health outcomes of groups of individuals, including the distribution of such outcomes within a group. So the approaches, again, could be on health outcomes or health determinants or policies and programs that might link both.

And finally, what can you do? You can cast an equity lens on all decision and action plans. You can become aware of your unconscious bias, which might impact  how you make decisions via the research, patient treatment, or anything else. I think it is important to get culturally competent. Assumptions tend to go a long way and people do not seem to realize they are making assumptions that may or may not be correct. 

Target multiple speakers veteran populations for quality improvement and research projects. When we do overall projects, the overwhelming population is usually who you have as your target. But if you design projects that actually target specific vulnerable populations, then we tend to be able to have more answers in that regard. 

And then I want to walk you through the performance measures discussion that I brought up earlier. If we do this again, having gotten all the information that I have put out to you with such speed on this dialogue, if you repeat this exercise for several scenarios and cast an equity lens on it. If it is not a performance measure then the population being targeted for research project, the location of a committee based outpatient clinic. And so there are so many ways you can flip this and repeat this exercise for any scenario that is relevant to your work area. You would be surprised what a difference it makes to cast an equity on a particular issue.

And I think I am almost at the end. I was going to ask you a couple of questions. Did you know you may already be doing work that is addressing health disparity? The questions are – the other things I wanted to bring to your attention is if you are already working with a vulnerable population, you are in a position to make a difference. The demographics and vulnerable populations vary from VAMC to VAMC. And I do not want to give you the impression that one size is going to fit all. You can take control of the activities pertinent to your region/facility or demographics. Or you can pick an area – for instance, if you have highly rural areas or you have very urban areas, all of those things have challenges. If you have a second mix of demographics in terms of race and ethnicity, those things have their challenges. So being able to identify which ones are more pertinent to your area and designing projects that work around them would be helpful. 

And we would like to partner with you – and by “we,” I mean the Office of Health Equity – to learn about your best practices and your ideas for this journey towards health equity.

Again, I will leave you with a couple of quotes. The first one is talking about geography of opportunity and how that impacts our life and our life opportunities. And the second one is actually a document that the Marmot Review had also taken input from, which talks about that we need to get beyond listing and analyzing the health disparities and begin to do something about them.

And finally, that is my pitch usually – that the pursuit of health equity should be everyone’s business. It is a journey that takes time and effort. And the question I keep asking is, “What can you do today in your area of influence to improve health equity?” And if you do not take anything else from this dialogue today, I hope that you stop long enough to not take actions that increase the disparities. 

And with that, I just have a few links for you. The first one is a Call For Papers in case the print was too small in the PDFs you received. The second one is the National Partnership for Action that I referred to. The third is Economic Burden of Health Inequalities in the United States and there are similar figures for global scale, as well. And the Office of Health Equity, of course. We invite you to visit our home pages within the VA intranet.

And this is the link that, again for me, there is no conscious or unconscious bias for pointing you to the side but it is a free demo exercise that you can take privately that also gives you a general idea of what your unconscious inclinations are to the various vulnerable populations. So I encourage you to do the exercise. You do not have to be within VHA network to do it. You can do it from home and it gives information that I think on a personal and professional level is useful. And if you need to make contact with me, that would be the email address. Just remember the “2” at the end of my  name. And no, there are not two of us in the VA. When you move from side to side, sometimes you become a number 1 or 2 as the case may be.

So that is all I was hoping to share with you. Again, thank you so much for logging on and listening and I would be glad to take any questions. And Molly, I am good with time so even if we go over an hour, I am willing to stay on if there are enough questions to warrant that.

Moderator:Great. Thank you so much, Dr. Uchendu. We do have several questions pending but before we get to that, we are lucky enough to have Dr. Elizabeth Yano on the call. She is the Director of the Women’s Health Research Consortium. So I would like to give her the floor to make a few comments real quick.

Dr. Elizabeth Yano:Thank you so much, Molly, and thank you – can you hear me all right?

Moderator:Yes.

Dr. Elizabeth Yano:Okay. I just wanted to thank you, Dr. Uchendu, for your time today and for graciously presenting this incredibly important information that you have provided. This is originally really a research forum and yet, as you can see from the kinds of folks that have logged in, we benefit from a really strong research clinical and policy set of partnerships. And I have appreciated so much already how much you consider how research can help meet and contribute to the achievement of the goals of the Office of Health Equity and appreciate how much you have been a champion already of integrating and partnering with researchers to advance your goals and to really improve care for veterans. 

So I just wanted to also make sure folks that were aware of the VA Health Services Research and Development Service solicitation have not changed for a number of years but that is because it is broad enough to capture a lot of important areas. And in fact, in the area of racial/ethnic disparities, there is a call for proposals for interventions for reducing disparities. There is also a lot of women’s health, which you have mentioned. But there has been some amazing reductions in gender disparities in VA quality that the Office of Women’s Health Services has taken a leadership role in inpatient care services. 

And again, just wanted to thank you and everyone that called in today to participate in this important thinking that you are encouraging us to do – and action.

Moderator:Great. Thank you so much, Dr. Yano, for your comments. As I mentioned, we do have several questions pending so we will get right to those. A couple people have asked where they can get a copy of the slides. Those are available through a hyperlink in the reminder email that you used today to enter the session.

So the first question. What determines which differences become a health disparity or consideration?

Dr. Uchendu:The determination is – can you hear me?

Moderator:Yes.

Dr. Uchendu:Okay. It is a dialogue that is continuing, to be honest. There is not, you know, like if it is significantly significant and you make certain cutoffs if there is a difference of ten percent, if there is a difference of twenty percent. It is being defined depending on the issue at stake. And that is not my personal opinion only. It is also among a lot of people who are doing work in this area, that you have to take the situation in a case-by-case. For instance, sometimes the disparity is not necessarily a disadvantage so you have to take the whole thing into context.

I will share briefly an article that recently came through. It was not specific to VA but it was looking at men receiving angioplasties in a an urban area where there were differences in the income. And the people who got referred more for angioplasty were people who had insurance, who more likely that not lived in suburban areas. many were white. And those who did not did not make those criteria. But as it turns out, even though it was disparate healthcare, the people who did not get it as often were getting the standard of care that was approved. And so there were other factors driving those who had insurance and so on and so forth getting it more. And I bring that to show that every time there is a disparity, it is not necessarily negative. And that is why we have to analyze it and have a good understanding of it before determining what to do with it.

Moderator:Thank you very much. The next question we have that came in. Why, in your opinion, have we not made more progress in this area since we have been talking about health inequalities for so long?

Dr. Uchendu:Well, that is a difficult – I think part of it is once you see in the definition of the generations, there has been a lot of figuring out what the disparities are and why we have them. The next step that seems to be missing a lot, which you will notice in our Call For Papers, we are looking for interventions, as well. And I talked to Becky Yano on that quote, “Translating research into action.” And I think those are some of the places that there is work to be done. And that is not to say that every disparity is already understood. For each of the vulnerable populations, the journey is at a different phase. 

And so for instance, whereas in certain areas like mental health, we already know that certain things do exist as a disparity and we may know what to do about them. There are some areas where we do not even know if we have a disparity and so they are going to be progressing at different levels. And I think part of why there has been such slow action is that we have not been translating the research into action.

Moderator:Thank you for that reply. The next question. What support does this office provide towards development – I am sorry. What support does this office provide  towards development of career development awardees? For example, vetting of ideas, assistance with identifying reviewers, other resources.

Dr. Uchendu:Like I mentioned, we are eight people strong. But one of the roles in the office is also synergy, breaking down silos, coordinating efforts, and all of those keywords. And so we are in a position to make linkages where necessary. The expertise might not always lie within my office. There are some that you might find the expertise within our office. But the intention is for us to be that connecting dot for all the various teams. And once we set our health equity action plan with our priorities, we will be in a better position to throw our weight behind certain specific research or projects that would answer the questions we need answered in the short-term and also, set those in motion for the long-term.

Moderator:Thank you very much. The next question that we have – pardon me. All right, let’s see, we have got a lot in here. How would you recommend we move forward in working to increase awareness and sensitivity to these issues among colleagues who may not initially see the importance of these issues?

Dr. Uchendu:I think that is part of why the charge in my office is to have an effective VA-wide communication plan and we will be addressing it from that angle. But the other piece is to dialogues like this. Being able to share this material with you in this forum, I am expecting that you will also be first, more compliant with it as far as sharing that with other people in your circle. We are hoping to increase the awareness with regard to cultural competency because a lot of people tend to feel like, “Oh, I know enough about this stuff. I do not need to have reminders about it.” But you would be amazed how much people do not know. I put in the definitions of equity and disparity even though I knew I was speaking to a predominantly research group that would know. Because a lot of people, in dealing with vulnerable populations, did not know those pieces.

So I think the long answer is it is going to be a while but it is a project that we can all engage. And if you talk to one colleague who talks to another colleague, that is a good thing. In addition, our office will be deploying a systemwide communication strategy that will hopefully help the dialogue.

Moderator:Thank you. Do you anticipate then emphasis on patient centered care will help to improve health equity?

Dr. Uchendu:Yes, I do, actually. And if you notice from the goal, the same goal that we are under on goal one, also has patient centered care as one of the objectives in there. And one of the offices that we are partnering with is the Official Office of Patient Centered Care and Cultural Transformation. Even we are looking at possibilities of weaving some of the angles of cultural competencies to some of their training. We are looking at PACT, which is what I showed you with the pilot that is going on in that piece. And in addition, also, the team approach that the VA is encouraging the team based approach of taking care of veterans, being able to at least, in those teams, bring in equity lenses in various shapes and forms. 

Yes, so I believe that patient centered care will definitely move the dialogue forward.

Moderator:Thank you. Exactly who should be contact in the Office of Health Equity and CHERP to initiate partnership with other VA national programs with a specific disease focus?

Dr. Uchendu:For my office, you can contact me directly. And based on the specific question, we will figure out what else to do with it. CHERP, Dr. Said Ibrahim and Dr. Michael Fine, both concomitant-directors of CHERP and I believe their information will be – and CHERP does have a website, as well.

Moderator:Thank you. Next question. Is this something that we will be starting soon at each VA facility? Or is it something that is just starting now? When can we expect to see some sort of training start?

Dr. Uchendu:It is hard to give you an immediate timeline on that. Because like I said, the action plan is going through ratification but we are expecting some activity this fiscal year. And depending on which vehicles we are able to use, it might come sooner than later. For instance, if we are going to fit into existing vehicles, sometimes it is easier and sometimes it is harder. So I do not have the exact answer for that question but I know that we are moving towards having activities get started.

Moderator:Thank you. Before we get to the remaining questions, I just wanted to let you know that several people have written in thanking you and Dr. Yano for an excellent presentation and it has been very helpful. So I encourage those people to reflect their opinion in the audience survey that will pop up after the session is over. 

And the next question. Given the findings from QI projects are not generally published in traditional research arenas like peer review journals, what role does the Office of Health Equity play in disseminating these findings so that we can all benefit from each others’ efforts?

Dr. Uchendu:Well, it is part of our awareness and communication goals. The Office of Health Equity has also had some dialogue with Office of Research and Development about encouraging some of these activities and figuring out the middle ground. And in addition, we hope to be able to have vehicles for publication that are not purely research only that would help us share this information. And there are, like I talked about, the Federal Interagency Health Equity Team – that vehicle is also moving in terms of collecting ideas that are happening in various federal agencies. There has been some dialogue about a possible global consortium for health equity. 

And so there will be vehicles. I cannot give you all the specifics on this particular call but that is something that we are keeping in mind. And the same time that I referred to that happened in July. That was a question that did come up, too, that you know, researchers are used to being researchers. But we are asking for implementation on projects that can move a little bit faster, what would be their recourse for not being able to get it through the peer review journals.

Moderator:Thank you. And what kind of research partnership or resource could the Office of Health Equity offer to researchers?

Dr. Uchendu:It is not fully defined at this point. We are looking at possibilities in terms of funding. We are not at the level of funding that some of other offices might be, at least not in this fiscal year, because we are still charting the path and figuring out how best... But we are partnering with offices like Office of Research and Development, Rural Health, and others that have been better and well established than we are from being around over the years. And so we are exploring the possibilities. That is a question that I could reserve an opportunity to come back to after we have clearly mapped out those paths.

Dr. Elizabeth Yano:If I may add, though, to it, I know that last year, there were some extra HSR&D funds and one of the things that HSR&D leadership put out there was you know, were there special initiatives people were interested in proposing around disparities research. And this year, they have kind of told us center directors to both be prepared for a possible ten percent sequester, might take a percent off of your center course, we will see what happens. Or it is going to be blue-sky thinking and we are going to have too much money. So this is the nature of doing this kind of work in an uncertain governmental situation. But I would suspect that it would be very good for folks to think about the kinds of disparities, relevant research they might propose in the event that there are RFAs in the middle of the year that propose highly relevant partnered research opportunities. 

As many of you know, both the create and the coined funding mechanisms are focused on partnered research. And if at least my sense from talking to Dr. Uchendu that if you are proposing work in a really highly relevant area for funding by VA HSR&D or a query or something that is going to meet needs within their mission, that you might be in a position to provide a letter of support. It depends upon the project, I am sure. But even that kind of partnership without money on the table can be extremely important. Would you agree, Dr. Uchendu? 

Dr. Uchendu:Yes, you put it more articulately. Thank you. [laughter] 

Moderator:Thank you, Dr. Yano. And the final question we have. What are some experimental exercises or activities have you found useful in eliciting aha moments – often crucial in engaging providers and working towards health equity?

Dr. Uchendu:Hmm. We do have an Unconscious Bias video actually that is out. Again, it was used within the PACT team. It was developed along with EES and until we finish the pilot, we probably would not be able to put that out completely. But again, it contains some examples that bring people to say, “Oh, yeah, you are right,” in terms of just the way someone gets treated and the choices they make reflecting whatever unconscious bias people have and do not even realize they have it. Everybody who is asking for a pain medicine is not necessarily selling it at the parking lot. There are actually those who have true pain and are running out of their medication. Just being able to come to the table with that realization. 

And I guess on a personal note, I can give an example of a situation not in my current role but where there was a discordance between the patient and the physician about their pain medicine. And the patient was swearing they were taking it as prescribed but they ran out. But their drug screen was not quite what it was expected to be. Long and short of the story was the particular drug they were taking was not picked up by the particular test that was done by the lab. So technically, yeah, the doc was right in saying the patient was not taking the medication. But there was that lack of benefit of doubt in the dialogue. And if you flipped a few things in the demographics of that patient, it might have been a different dialogue.

And so just being able to come to that place and realize that the person did not set out to treat anybody differently or perceive a situation differently, but it is just human nature.

Moderator:Thank you very much for illustrating that for us. And that is the final question that has come in. Dr. Uchendu, do you have any final comments you would like to make?

Dr. Uchendu:Well, again, I want to thank you, Molly, for the opportunity to do this and you know, helping me work behind the scenes to get to this point. I want to thank also Becky for chiming in and in addition, all the others who have shown their support for the Office of Health Equity before giving and after our launch, and have continued to feed ideas and comments and suggestions even though we are not in a position to do all the things that might be on our wish list. I wanted to say that I would like to continue the dialogue and we are working towards crystallizing certain things and being clearer on the level of support we can provide. But I can promise you that where we are not able to, we can make the linkages and start the dialogue. And the approach that the VHA has taken for achieving health equity is not that this office will do everything about it. The office is supposed to create awareness, harness efforts, and all of those things. But the actual action lies with every one of us in whichever areas that we are. 

So again, thank you for joining the dialogue and I know we will continue to have it. And hopefully, we will make more progress then between the two courses of the 1966 and the 2012 in a few years. Thank you.

Moderator:Excellent. Well, we would also like to share our thanks for you presenting to us and sharing your expertise, along with Dr. Yano. And I just want to let our attendees know that when I close the meeting in just a second, a survey will pop up on your screen. Please do take just a moment to fill out those few questions, as it is your opinion that drives where the program goes.

So thank you once again to Dr. Uchendu and Dr. Yano, and to our participants for joining us today. Have a wonderful day.

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