What additional actions can be taken to address health disparities in vulnerable populations?

Addressing Health Disparities in Vulnerable Populations: Evidence-Based Action Items

Core Recommendation

Implement systematic screening for social determinants of health (SDOH) in all clinical encounters with vulnerable populations, coupled with direct linkage to community resources through trusted intermediaries. 1

Multi-Level Action Framework

Individual Provider Actions

Screen every patient for SDOH using a structured, non-biased approach during office visits. 1 This is critical because 70% of physicians demonstrate implicit preference for whites over blacks, which directly affects medical decision making, communication, and nonverbal behavior. 1

• Connect patients immediately to social service resources such as findhelp.org (formerly Aunt Bertha) and 211.org during the clinical encounter. 1
• Provide culturally sensitive disease education tailored to the patient's language, literacy level, and cultural context. 1
• Engage in mandatory implicit bias and cultural competency training to increase self-awareness of how personal biases affect clinical decisions. 1
• Recruit and hire diverse patient-facing faculty and staff to reflect the communities served. 1

Community-Level Interventions

Build formal partnerships between health systems and community-based organizations to deliver care through trusted intermediaries in non-traditional settings. 1

• Deploy telehealth through trusted community venues including libraries, places of worship, laundromats, barber shops, and fire departments where vulnerable populations already spend time. 1, 2
• Establish school-based health programs partnering with faith-based organizations to provide education, telemedicine visits, and medication administration directly in schools. 1
• Create community health forums where members can express concerns directly to providers, health systems, payers, and legislators. 1
• Provide local resources including fresh food markets, smoking cessation programs, exercise and nutrition classes, and free support groups. 1

Health System and Organizational Strategies

Implement culturally tailored, patient-centered telehealth solutions that specifically address SDOH barriers faced by vulnerable populations. 1

• Use low-cost text messaging and smartphone-based interventions since 71% of households earning under $30,000 own smartphones, making this the most accessible technology. 1
• Deliver interventions through community health workers who serve as trusted intermediaries between health systems and vulnerable communities. 1
• Adopt community-based culturally tailored education (CBCTE) programs that integrate peripheral strategies (targeting specific communities), constituent-involving approaches (community-informed design), evidential methods (integrating community resources), linguistic adaptations (using community dialect), and sociocultural elements (incorporating religious practices). 3
• Optimize health information technology to improve access for underserved groups to medical care. 1

Policy and Advocacy Actions

Advocate for removal of race-adjusted clinical algorithms that systematically direct more resources to white patients than to racial and ethnic minorities. 1

• Push for increased Medicaid and Medicare reimbursement rates comparable to private payers to equalize access to specialty care. 1
• Advocate for elimination of financial barriers to preventive services in all public and private health insurance plans. 1
• Support government funding for health-promoting efforts aligned with value-based care and antiracist research agendas. 1
• Promote tax incentives for physicians providing charity care and partnering with community organizations in medically underserved areas. 1

Implementation Best Practices

Co-design all programs with direct input from community members rather than imposing top-down solutions. 1, 2, 4

• Ensure intensive personalization and cultural tailoring during initial planning phases and ongoing throughout implementation. 1
• Use multifaceted, intense approaches rather than single interventions, as these have demonstrated improved health outcomes in disadvantaged groups. 4
• Establish partnerships with payers early to facilitate reimbursement and ensure program sustainability. 1
• Measure intervention durability over time rather than just immediate outcomes. 1

Critical Pitfalls to Avoid

Do not assume access to care alone will eliminate disparities - interventions must specifically address SDOH including food insecurity, housing instability, transportation barriers, and educational gaps. 1, 4

• Avoid delivering programs in only one location - use multiple community sites to broaden reach. 3
• Do not implement telehealth without addressing the digital divide - differences in internet access can worsen disparities rather than reduce them. 1
• Never overlook the need for linguistically appropriate services - provide materials and interpretation in patients' preferred languages. 1
• Do not neglect workforce diversity - implement specific programs to recruit and retain minorities in healthcare professions through task forces and policy-making committees. 1

Interprofessional Collaboration Requirements

No single healthcare profession can address health disparities alone - systematic collaboration across all healthcare providers is essential. 5

• Designate one clinician to coordinate all medical and health-related needs for patients with complex conditions. 6
• Involve community health workers, nurses, social workers, and faith leaders as core team members, not peripheral consultants. 1
• Establish formal care coordination systems spanning prevention, primary care, specialty care, hospitalization, and post-discharge treatment. 1