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Macon, Ga.-based Navicent Health received the 2018 AHA Equity of Care Award by transcending the , which asks hospital and health system leaders to collect more sociodemographic data from their patients; increase cultural competency training within their organizations; boost diversity within their leadership and governance teams; and enrich their organization’s community partnerships.

Navicent Health, under the leadership of CEO Ninfa M. Saunders, who was a previous chair of the board of directors for the AHA’s Institute for Diversity and Health Equity, took the pledge to heart. The health system improved readmission disparities among African Americans; it resolved readmission health disparities among African American patients with chronic obstructive pulmonary disease, heart failure, and diabetes; and it reconciled health disparities among women with diabetes.

It also diversified its board and leadership to such an extent that its employees said the organization felt more equitable, said Roy Gilbreath, senior vice president and chief system of care integration officer. It partnered with civic, educational and religious organizations; it funded Macon-Bibb County’s Federally Qualified Health Center; and it developed approximately 100 new access points for vulnerable populations throughout its region. 

Gilbreath said that it achieved all this by taking a big-picture view of its role as a health organization. Not only does Navicent Health provide care, it considers itself “a convener of health” within its community, Gilbreath said.

“We became the collector and collaborator in linking all these [local] organizations together,” Gilbreath said. “We're simply able to educate patients on where to go to get the care that is there.”

Navicent Health was able to facilitate such learning through its team of community health workers, who were particularly helpful in helping it resolve heart failure discrepancies. To this end, Navicent Health went to great lengths to make sure anyone with heart problems was able get care, even if they couldn’t pay for it. 

“A lot of the attempts by the care coordinators were to get the patient into our heart failure clinic,” Gilbreath said. “Or if the patients had another primary care physician or a cardiologist, the idea was to ensure primary care access and specialty care access.”

Gilbreath credits Navicent Health’s respiratory therapists, who voluntarily took on community health worker roles when working with patients with chronic obstructive pulmonary disease, with helping resolve this disparity. These staff educated and followed up with patients after they’d been discharged, using social determinants data to tailor care strategies to individual patients, he said. 

“They intervened in many different ways, making sure the patients did indeed take their medicine, adhere to diet, understood pulmonary rehab, smoking cessation and had a primary care follow-up plan,” Gilbreath said.

Chronic obstructive pulmonary disease readmission rates were cut in half as a result of these interventions by respiratory therapists, reaching a number Navicent Health has sustained for four years-and-counting, Gilbreath said.

In order to execute these strategies, measuring social determinants data was key. Navicent Health relied on Quantros, its comparative database, to identify severity-adjusted disparities within its patient populations. With this conclusive data, Navicent Health was able to address disparities and statistically measure its success in doing so. Other hospitals should be able to emulate this without great expense, Gilbreath said.

“A lot of people think they have to approach this as an intense research study where charts are abstracted, costing hundreds of thousands of dollars,” Gilbreath said. “We just looked at outcomes using our database of the patients that we see anyway.”

Another key to Navicent Health’s success, and critical to any organization that is focused on health equity, is the importance to have it embedded within your organization’s strategic goals. 

“At Navicent Health, one of our guiding objectives is to create healthy communities and the success around health equity is a key outcome that is woven throughout our initiatives supporting that guiding objective,” Gilbreath said.