Health Equity: Addressing the Full Scope of Patient Needs

At Northwestern Medicine , our health equity work has led us to recognize the significance of the social determinants of health (SDOH), defined by the U.S. Department of Health and Human Services in their Healthy People 2030 initiative as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” The fact is that if you do not have a safe place to live, or access to healthy food or reliable transportation, you do not have “a fair and just opportunity” to be healthy.

Here in Chicago, health disparities are significant . As an example, the diabetes-related death rate among Black Chicagoans is 70% higher than among those who are not Black, and Black infants are almost three times as likely to die in their first year of life compared to non-Black infants. Our communities speak Spanish, Polish, Russian, Arabic, Mandarin and Hmong as well as many other languages, and we know that limited English proficiency contributes to difficulties in accessing health care.?

Our SDOH program

Northwestern Medicine created a program with a goal to identify and assist those with one or more SDOH needs that we can help address. Following a successful pilot program at 12 sites in 2021, our SDOH program was embraced systemwide. Screening and support are offered to every inpatient, every primary care clinic patient and patients in select specialty clinics.

Now, patients are asked a standard set of questions related to SDOH, such as:

• Do you have trouble getting transportation to medical appointments?
• Have there been times that your food ran out and you didn't have money to get more?
• Are you concerned about having a safe and reliable place to live?
• Are you worried that your electricity, gas, oil, or water might be shut off?
• Would you like to be connected to groups that can help with any of these topics?

Responses are captured in the patient’s electronic health record (EHR). If the patient answers yes to the last question, the EHR is programmed to make it simple for clinicians to access information on Northwestern Medicine resources and local community organizations that can help. This information is incorporated into the patient’s discharge information and their individual online health information portal.

Patients in the hospital meet with a social worker to discuss referrals and next steps. Outpatients receive a follow-up call from a Community Health Worker on our Outreach Team within two days of their visit.

These phone calls have proven to be a powerful way to build a personal connection with the patient. Our team is highly diverse with a range of spoken languages, which helps build trust. About 70% of patients engage with staff members through these phone calls, and about 30% indicate that they would like us to help them in one or more ways.

This extraordinary team can offer a variety of assistance, such as connecting patients with:

• A food pantry in their neighborhood
• A housing assistance agency
• Transportation for their next appointment
• Programs offering discounted medications

Since 2021, we have screened more than 800,000 patients for SDOH. Today, we are screening an average of 32,000 patients every month, and more than 15,000 have been connected with resources that will give them and their families a better opportunity to live a healthy life.

Spreading the impact to communities

Referring patients to local organizations is not the end of the story. Some of the organizations that step in with support have a long history of partnering with Northwestern Medicine in a variety of ways to meet our patients’ needs.

The SDOH program has helped us understand the types and extent of needs in our communities, which means we are better able to work with community organizations and local leaders on the greatest community priorities. We support these organizations in three critical ways:

• Provide grant funding to ensure they can effectively serve the communities
• Share our expertise by offering health and wellness education and screening to their clients
• Support them with staff and volunteers through our employee volunteer group, Team NM

Staff members are also thinking about how they can impact health equity. They can apply for funds through the Northwestern Memorial Foundation Healthier Communities Grant program to create unique local programs that specifically address SDOH for patients they serve. Grants range from $10,000 to $25,000 and have been used for a variety of initiatives, such as to:

• Establish a mobile food pantry
• Pay for food and transportation for patients and organ donors
• Provide free car seats to families
• Provide vouchers for heart-healthy foods to patients with acute heart failure

Bringing care closer to home

Location is also closely tied to equity, as challenges with transportation, the time for travel and the cost of parking can become barriers to care. In 2019, we identified a unique opportunity to better serve residents in Bronzeville and surrounding neighborhoods on Chicago’s South Side. Many people from this area were traveling outside of their community to get care at Northwestern Medicine, so we developed a plan to build a new 120,000-square-foot outpatient center in Bronzeville .

The center has been carefully planned not just to be a convenient place to get care. We worked closely with residents through surveys and listening sessions to understand their hopes and dreams for how this center could enhance this vibrant community and address other SDOH.

With their engagement and under the leadership of Medical Director Kimbra Bell Balark, MD, FACP , we are making sure the center will support the health and well-being of Bronzeville residents by:

• Improving access to leading-edge care without traveling far from home
• Fueling economic growth, with the inclusion of retail spaces and hiring of staff from the community
• Providing gathering space to support local community residents and organizations

Northwestern Medicine Bronzeville Outpatient Center is now under construction and set for a 2025 opening.

Next steps in health equity

We have made tremendous strides in health equity, but we can always be better. That’s why I named Dinee Simpson, M.D. , as our new Chief Health Equity Executive.

Dr. Simpson is well-suited to drive health equity initiatives at Northwestern Medicine. She came here as a transplant surgeon with a specific goal: to address racial disparities in organ transplants. Her passion led her to become the founding director of the Northwestern Medicine African American Transplant Access Program , and now she and program staff members are helping more Black people overcome obstacles to liver and kidney transplants.

Building trust and engaging with the community has been critically important. The program evaluates each patient to identify barriers to transplant, such as challenges around social support, insurance, transportation, navigating complex medical diagnoses, adherence and self-activation. It then provides support and resources to help overcome those barriers. A dedicated health literacy and wellness coach at the clinic supports patients through their transplant journey.

The program results have been extraordinary. In just the first two years, Northwestern Medicine saw:

• A 55% increase in transplant evaluations of Black patients
• An 18% increase in Black patients on the transplant waiting list

Since the program’s inception:

• More than 275 patients have been seen
• 74 have been listed
• 46 have been successfully transplanted
• More than 100 are active along the evaluation path to listing

With the experience she has gained in this thriving program, I look forward to seeing what Dr. Simpson will achieve in her new health system equity-focused role.

The journey continues

As an academic health system, we are privileged to train future clinicians. Many of our medical students, residents and other trainees are involved in our SDOH program, and we encourage them to present their work at national conferences to help inspire other health systems to adopt a similar program. It is gratifying to know that as they complete their medical training, they will bring their knowledge and experience to other organizations across the country.

“Better” is a journey at Northwestern Medicine, and in the face of so many health disparities in our communities, better health equity is essential. I am proud to lead an organization that is driven to help people live better, whether that is in our hospitals and clinics or in the communities we serve.

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Howard B. Chrisman, MD, is president and CEO of Northwestern Memorial HealthCare. He oversees the Northwestern Medicine healthcare system, including 11 hospitals, more than 200 ambulatory and diagnostic sites, and over 30,000 employees and 5,500 aligned physicians. Dr. Chrisman continues to serve as a professor of Radiology and Surgery at Northwestern University Feinberg School of Medicine, and is clinically active with a primary expertise in treating fibroid disease using endovascular techniques.