December 2024

The benefits of providing culturally concordant care have been long known. Research shows that health systems and clinics that have practitioners who reflect the community report higher patient satisfaction, improved patient-doctor communication, and greater trust in the health care system. These factors lead to improved adherence to treatment plans, and ultimately better health outcomes. Swope Health is a witness, and they are in good company. Health systems like Cleveland Clinic, UCLA Health, Massachusetts General Hospital, and the Veterans Administration, among others, report the same outcomes.

Swope Health, a federally qualified health center (FQHC) located in the urban core of Kansas City and Wyandotte County, Kansas, serves nearly 60,000 patients per year. Swope Health is also one of 15 KC Health Equity Learning and Action Network  (LAN) members. Action teams commit to taking equity-centered methodologies back to their respective institutions, identify practices that perpetuate injustices, and develop coherent strategies to address them through an anti-racist lens. 

Prior to joining the LAN, Swope Health elected to reduce health disparities among diabetic patients by focusing on social drivers, like food insecurity, transportation, and housing. This work was one of the FQHC’s strategic goals developed in 2021 during the height of the COVID-19 pandemic, aligns with their five-year strategic plan, and serves their action team focus for the LAN. 

Ultimately, the LAN’s goal is to eliminate disparities in health care delivery while realizing measurable improvements steeped in equity-centered, culturally responsive health outcomes for all health care consumers. LAN action teams address everything from birth equity as it relates to Black maternal and infant health, to equitable measurement of kidney disease acuity, treatment options, and transplant referrals for Black patients – to name just   

Swope Health’s role in the LAN, Naiomi Jamal, M.D. said, provided community, and deeper, more meaningful relationships with area partners. Swope Health had long before made a commitment to health equity to improve patient outcomes. What the LAN did was provide a safe space to have candid, honest conversations about race, racism, and health care.

“I felt everyone was in the same space together, having meaningful, important, and frank conversations,” she said. “People expressed how things were really going. It is important for us to be honest about our challenges with whatever is happening, whether it’s implicit bias, racism, or other issues – and how those challenges impact the work we’re doing, and the impact we are trying to affect. It was some very real talk.”

This talk resonated with organizations previously challenged by the notion that health and racial equity do in fact impact health outcomes. They, too, engaged in open conversations about how they could do better in this space. “It felt like a brotherhood was created,” Dr. Jamal said.

Although health and racial equity have been the ethos of Swope Health’s care delivery model even prior to joining the LAN, their work with diabetic patients offers clear evidence that culturally concordant care is as crucial to patient health outcomes as prescribing the right treatment plan.

“If someone had an A1C above 6.5 and we weren’t talking to them about starting metformin, it would be considered negligent to ignore the data and not follow appropriate guidelines,” Dr. Jamal said. “Similarly, there’s enough evidence that shows the importance of care teams being reflective of the communities that they serve. We cannot ignore the data in this case, then feel surprised when health disparities based on race continue to persist.”

Swope Health screens patients for three social drivers – food, housing, or transportation insecurity – anyone who identifies with at least one is paired with a community health worker who conducts the full PRAPARE assessment. For their role in the LAN, Swope Health took its chronic disease data for diabetes and married it with food insecurity. And they did this using race, ethnicity, and language (REL) data to understand the unique health risks and health care needs of their diabetic patients.

“We analyzed the data to see if there were any disparities,” Dr. Jamal said. “It was really interesting because the communities we serve,  in ZIP codes 64130 and 64128, for instance, have the highest diversity coefficients (differences between individuals within a given population) in Kansas City, but also have some of the worst health outcomes in terms of life expectancy – and disparately for people of color.”

Even though the community had high rates of health disparities, when it came to the patients Swope Health treated for diabetes, there were no disparities from a gender or racial perspective. But what they did see were pronounced disparities among their uninsured population.

“Our leadership team and our board look like the community we serve. It’s at every level.,” Dr. Jamal said. “For us it is very, very reinforcing because even though the community showed great health care disparities, when those patients with diabetes came to Swope Health, that racial disparity [disappeared]. That was impactful for us and reinforced that this is meaningful.”

During COVID-19, additional funding offered a financial buffer for a nurse care management program that provided wraparound services to address both health care and SDOH for uninsured patients with uncontrolled diabetes. This program mirrors what Medicaid-insured patients had already been receiving.

Post-pandemic, funding for uninsured patients evaporated. With some internal reworking, Swope Health opted to maintain the same level of whole-person care without outside financial support. And it’s working. “So, the data told us that we need to continue this program around uninsured, uncontrolled diabetes because we figured out that they were our highest-risk diabetic patients,” Dr. Jamal said.

At one time, their uninsured population was around 50%. With help from the Affordable Care Act (ACA) and Missouri Medicaid expansion, uninsured patients now account for about 20-30%. Primarily, these patients fall into the donut hole – they make too much for Missouri Medicaid but cannot afford ACA coverage. Additionally, some have been kicked off Medicaid due to redetermination.

For their Wyandotte clinic on the Kansas side, the dynamic is a bit different. Roughly 70% of their patients are Spanish-speaking, and many are without legal status, which prohibits access to safety net programs. For others, gaining insurance coverage is moot because Kansas has yet to expand Medicaid.

To be eligible for the nurse care management program, patients must be uninsured and have an A1C above 9. “And with that, they have a dedicated nurse care manager, often an R.N., who connects with them on a monthly basis, provides evidence-based education, gets them to their appointments, does an SDOH screen, and connects them to either internal resources or finds resources for them externally,” Dr. Jamal said.

These nurse care managers also work with these patients to help them meet the goals they’ve defined with their provider. Dr. Jamal said they also look like their patients. This includes their Wyandotte clinic which is staffed by Spanish-speaking professionals who were recruited from the same community.

“The great thing about that is they are able to talk with them about diet and food that is culturally relevant and accessible,” Dr. Jamal said. Nurse care managers suggest culturally congruent food options that help patients improve their A1C, provide help with access to needed medication, and address social circumstances or disease complexities.

Some might say this is all well and good, but how will these efforts be sustained in a climate where diversity, equity, and inclusion (DEI) policies continue to unravel? Cecilia Saffold, CEO of HealthTeamWorks, and a LAN facilitator, said four years ago, it was very common to speak about DEI and about health equity and the strength it harnessed when both workforce and leadership represented the patients it served. It was something heralded. Now, it’s looked at less as a unifier and more as a divider. She said the onus will be on the LAN to keep organizations on course.

“The action teams doing the work are laser-focused,” Saffold said. “But keeping leadership teams focused on and invested in the work, provisioning time for this work, and resources will be the major challenge.”

As for Swope Health, their commitment to health equity remains strong and is one way they measure success. Dr. Jamal credits the LAN with reinforcing the meaningful collection and use of data to help them see outcomes from a variety of perspectives to gauge success. In the beginning, Swope Health simply analyzed diabetes outcomes. Now, they look at patient experience scores and dissect that data through multiple lenses. “We are looking at different sets of data that we’ve collected organization-wide and report out to our board not only what our patient experience scores look like, but what they look like for different groups and whether significant disparities were noticed within these different groups. That is one measure of success for us.”

Ultimately, health care organizations, in addition to improving health outcomes for communities, also serve as economic engines of opportunity for those same communities. Swope Health’s commitment to hiring from the community, be it in rural Kansas, Missouri, or the urban core, makes it a true community health center.