Objective 1.3: Expand equitable access to comprehensive, community-based, innovative, and culturally-competent healthcare services while addressing social determinants of health

HHS invests in strategies to expand equitable access to comprehensive, community-based, innovative, and culturally- and linguistically-appropriate healthcare services while addressing social determinants of health.  HHS supports community-based healthcare services to meet the diverse healthcare needs of underserved populations while removing barriers to access to advance health equity and reduce disparities.  The Department also works to understand how to best address social determinants of health in its programs. 

Objectives represent the changes, outcomes and impact the HHS Strategic Plan is trying to achieve.  This objective is informed by data and evidence, including the information below. 

• Social determinants of health (SDOH) are 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.  (Source: Social Determinants of Health)
• In 2018, the percent of persons with a usual place to go for medical care was 87.6 percent.  (Source: Early Release of Selected Estimates Based on Data From the 2018 National Health Interview Survey)  There are considerable racial/ethnic disparities when it comes to who has a usual place to go for medical care.  Specifically, in 2018, Hispanic adults (74 percent) and non-Hispanic Black adults (80 percent) are less likely to have a usual place to receive care compared to non-Hispanic Whites (86 percent).  (Source: QuickStats: Percentage of Adults Aged 18–64 Years with a Usual Place for Health Care, by Race/Ethnicity—National Health Interview Survey, United States, 2008 and 2018)
• In 2020, health centers served 28.6 million patients and provided 114.2 million patient visits.  (Source: 2020 Uniform Data System Trends).  More than 91 percent of health center patients are individuals or families living at or below 200 percent of the Federal Poverty Guidelines.  (Source: Biden-Harris Administration Provides Nearly $1 Billion in American Rescue Plan Funds to Modernize Health Centers and Support Underserved Communities)  62.24 percent of patients are of a Racial and/or Ethnic Minority and one in five rural residents are served via the health center program.  (Source: 2020 Uniform Data System Trends)
• Variability in the risk of death by race/ethnicity may be due to several factors including access to care, quality of care, prevalence of chronic diseases, structural racism, and implicit biases.  (Source: Pregnancy Mortality Surveillance System)
• Deaths during pregnancy, or up to one year postpartum due to pregnancy-related causes, are higher in rural areas compared to metropolitan areas.  Mortality is higher in underserved areas with lower numbers of certain healthcare providers per capita.  (Source: Maternal Mortality and Morbidity: Additional Efforts Needed to Assess Program Data for Rural and Underserved Areas)  There are considerable racial/ethnic disparities in pregnancy-related mortality.  Notably, during 2007–2016, the rates of pregnancy-related death among African American and American Indian/Alaska Native women were 3.2 and 2.3 times the rate for White women.  (Source: Morbidity and Mortality Weekly Report (MMWR), Racial/Ethnic Disparities in Pregnancy-Related Deaths—United States, 2007–2016)  Moreover, about 66 percent of pregnancy-related deaths are considered preventable.  (Source: Data Brief from 14 U.S. Maternal Mortality Review Committees, 2008-2017)
• The characteristics of rural health and human service disparities include poorer health status, with residents of rural areas more likely than their urban counterparts to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke, and to have healthcare and human service workforce shortages, fragile provider networks, and the limited and varied capabilities of public health and human services departments, among others.  (Source: Rural Action Plan, September 2020)
• Oral diseases—which range from cavities to gum disease to oral cancers—cause pain and disability for millions of Americans.  One in five U.S. children aged six to 11 has at least one untreated cavity.  One in four adults has untreated cavities, and more than 40 percent have felt pain in their mouth in the last year.  On average, 34 million school hours are lost each year because of unplanned (emergency) dental care, and over $45 billion is lost in productivity due to untreated dental disease.  About 100 million Americans do not have access to fluoridated tap water, and six in 10 children do not get dental sealants.  (Source: Division of Oral Health At A Glance)
• Populations disproportionately affected by coronavirus disease 2019 are also at higher risk for oral diseases and experience oral health and oral healthcare disparities at higher rates.  COVID-19 has led to closure and reduced hours of dental practices except for emergency and urgent services, limiting routine care and prevention.  (Source: Oral Health and COVID-19: Increasing the Need for Prevention and Access)
• In a 2017 survey, 32 percent of Black adults and 33 percent of Hispanic adults said it was very important to have a healthcare provider who shared or understood their culture, compared to only 13 percent for White adults.  Among respondents who said it at least somewhat important to have a healthcare provider who shared or understood their culture, 78 percent of White adults were able to have this kind of healthcare provider always or most of the time compared to 60 percent of Black adults and 59 percent of Hispanic adults.  (Source: Reported Importance and Access to Health Care Providers Who Understand or Share Cultural Characteristics With Their Patients Among Adults, by Race and Ethnicity)
• Patient safety events that can result from the failure to address culture, language, and health literacy include diagnostics errors, missed screenings, unexpected negative responses to medication, harmful treatment interactions from simultaneous use of traditional medicines, healthcare-associated infections, adverse birth outcomes, inappropriate care transitions, and inadequate patient adherence to provider recommendations and follow-up visits.  (Source: Cultural Competence and Patient Safety)
• Since the start of the COVID-19 pandemic, there has been a surge in telehealth adoption and usage by healthcare providers, telehealth providers and health insurers.  (Source: Medicare Beneficiary Use of Telehealth Visits: Early Data from the Start of the COVID-19 Pandemic)  99 percent of health centers offered virtual visits in 2020, compared to 43 percent in 2019.  (Source: 2020 Uniform Data System Trends)  States have embraced Medicaid telehealth flexibilities during the COVID-19 Public Health Emergency (PHE), enhancing beneficiary access to services delivered via telehealth.  (Source: State Medicaid Telehealth Policies Before and During the COVID-19 Public Health Emergency)

Contributing OpDivs and StaffDivs

ACL, AHRQ, ASPE, CDC, CMS, HRSA, IHS, NIH, SAMHSA, OASH, and OCR work to achieve this objective.

HHS OpDivs and StaffDivs engage and work with a broad range of partners and stakeholders to implement the strategies and achieve this Objective.  They include: the Advisory Committee on HIV, Viral Hepatitis and STD Prevention and Treatment, Advisory Committee on Heritable Disorders in Newborns and Children, Advisory Committee on Infant Mortality, Advisory Committee on Minority Health, Advisory Committee on Organ Transplantation, Advisory Council on Blood Stem Cell Transplantation, Cross Federal Workgroup on Telehealth, Federal Partners Workgroup to Improve Maternal Health, Federal Sudden Infant Death Syndrome/Sudden Unexpected/Unexplained Infant Death Workgroup, HHS Language Access Steering Committee, Interdepartmental Health Equity Collaborative, National Advisory Committee on Rural Health and Human Services, National Advisory Council on Migrant Health, National Advisory Council on the National Health Service Corps, National Committee on Heroin, Opioids, and Pain Efforts, Presidential Advisory Commission on Asian Americans, Native Hawaiians, and Pacific Islanders and the White House Initiative on Asian Americans, Native Hawaiians, and Pacific Islanders, and U.S. Department of Veterans Affairs.

Strategies

Support community-based services to meet the diverse healthcare needs of underserved populations

• Deliver safe, equitable, affordable, accessible, quality, value-based primary healthcare to underserved populations through health centers and other community providers.
• Address COVID-19 related health disparities and advance health equity by expanding state, tribal, local, territorial, and freely associated state health department capacity and services to improve and increase testing, vaccination, contact tracing and treatment to prevent and control COVID-19 infection or transmission.
• Ensure the provision of safe, culturally- and linguistically-appropriate care and services for women, with dedicated focus on African American/Black and American Indian/Alaska Native women and people with lower incomes, during maternal, prenatal, perinatal, and postpartum periods of life, including raised awareness of pregnancy-related risk factors and available benefits. 
• Work with tribal nations and Urban Indian Health programs to expand and improve pre- and post-natal care on Indian reservations and Urban Indian centers to reduce disparities in maternal and infant mortality and morbidity.
• Promote partnerships to implement programs and outreach that focus on raising awareness and rapidly linking affected individuals to relevant care and treatment services, including persons harmed by substance use disorders, and persons with HIV.
• Promote linkages to treatment and interventions aimed at reducing exposure and excessive use of alcohol and other substances to achieve healthier outcomes, including optimal pregnancy outcomes.
• Expand access to oral healthcare, including diagnostic, preventive, and restorative services, and healthcare settings that provide oral healthcare, and promote collaborative practices to integrate oral health and primary care to improve health outcomes.
• Continue to expand equitable access to quality sexual and reproductive health services, including family planning services.
• Continue to promote and support programs that invest in rural collaborations and encourage efforts designed to improve rural healthcare system capacity and infrastructure to facilitate delivery of equitable healthcare services that can comprehensively address the health, social, and economic needs of a wide range of population groups.
• Extend and enhance the lives of individuals in all communities through improving equitable access to safe organ transplantation, bone marrow transplants, and cord blood transplants. 
• Improve access to community-based care by supporting appropriate retention of telehealth flexibilities implemented for the COVID-19 pandemic, increasing access to broadband, and providing technical assistance, training and information for patients and providers on the use of telehealth technologies.
• Facilitate the delivery of technology-based interventions and innovations, including the development and dissemination of electronic health record standards, to enable interoperable data exchange across health and community service providers and emerging artificial intelligence solutions to improve care management.

Remove barriers to healthcare access to advance health equity and reduce disparities

• Build capacity of resource centers, healthcare organizations and the health workforce to reduce health and healthcare disparities, including cultural competence capacity to provide culturally and linguistically appropriate services (CLAS).
• Promote adoption of national CLAS standards to enable providers to demonstrate cultural humility through self-awareness and communicate in ways that consider the cultural, health literacy, and language access services needs of their patients. 
• In collaboration with private and non-profit organizations, develop patient safety bundles and decision aids like protocols and checklists for health conditions that disproportionally affect underserved populations and work with national accreditation organizations to promote their use in clinics across the nation.
• Collect, use, and monitor data on the prevalence, causes, and risks of social, environmental, and biological conditions, and establish partnerships between healthcare providers and community-based social service organizations to address social determinants of health.
• Support state, local, tribal, and territorial jurisdictions to develop multi-sector action plans to address social determinants of health, in sectors such as housing, transportation, and social services, and accelerate actions that lead to improved chronic disease outcomes among persons experiencing health disparities and inequities in communities with the poorest health outcomes.
• Collaborate with providers, health plans, patient advocates for people with disabilities, and other healthcare stakeholders to identify and remove barriers that individuals with disabilities face in accessing current and new services, procedures, and coverage.
• Increase access to affordable, accessible housing, and other services that address unmet social needs that contribute to poor health outcomes and reduce unnecessary healthcare expenditures through the HHS and U.S. Department of Housing and Urban Development housing partnership and other partnerships.
• Engage community members to provide input to plan and implement services and programs and conduct participatory research to ensure that activities are tailored and responsive to community needs.

Understand barriers to access and the impacts of social determinants of health to develop evidence-based community-based healthcare service delivery models

• Expand efforts to collect data that improves understanding of the social determinants of health and their implications for delivering equitable and effective health, public health, and human service programs.
• Partner with healthcare organizations, healthcare providers, social service organizations, and other organizations to identify, develop and implement evidence-based community-based healthcare service delivery models to support whole person integrated and coordinated care to improve physical health and behavioral health outcomes.
• Support community-based participatory research, and other research approaches, to examine and improve the effectiveness of community-based service delivery models, in improving health outcomes across populations, including collecting and stratifying data based on race, ethnicity, national origin (including primary language), sex, sexual orientation, gender identity, and pregnancy, age, disability status, and other population variables.
• Support research on telehealth to answer questions related to how it affects access, equity, quality, and costs of care, including for underserved populations.

Performance Goals

The HHS Annual Performance Plan provides information on the Department’s measures of progress towards achieving the goals and objectives described in the HHS Strategic Plan for FY 2022–2026.  Below are the related performance measures for this Objective. 

• Total number of IHS public health activities captured by the Public Health Nursing (PHN) data system; emphasis on primary, secondary, and tertiary prevention activities to individuals, families, and community groups
• Percentage of underserved population accessing mental health and substance use services
• Increase the likelihood that the most vulnerable people receiving Older Americans Act Home and Community-based and Caregiver Support Services will continue to live in their homes and communities
• Percentage of pregnant health center patients beginning prenatal care in the first trimester
• In collaboration with FEMA and DHS, OCR (Agencies) will conduct compliance reviews of select state COVID-19 vaccine provider programs to determine whether their services are being provided free of discrimination on the basis of race or national origin (including limited English proficient (LEP) persons and communities)

Learn More About HHS Work in this Objective

• Blueprint for Change: Blueprint for Change: Guiding Principles for a System of Services that Meet the Needs of CYSHCN and their Families: To advance systems and prioritize well-being and optimal health for children and youth with special healthcare needs (CYSHCN), HRSA’s Maternal and Child Health Bureau (MCHB) is developing developed actionable recommendations for the field that, if implemented, could advance systems and improve outcomes for CYSHCN and their families.  The recommendations will be published in early 2022.  
• CORE: Health Equity Strategy: Through the CORE strategy, CDC is integrating health equity into the fabric of our work at all levels.  Each division has submitted health equity action plans that are being incorporated into a broad, unified agency-wide strategy.
• Ending the HIV Epidemic in the United States: Aims to end the HIV epidemic in the United States by 2030 and the Ryan White HIV/AIDS Program provides a comprehensive system of HIV primary medical care, essential support services, and medications for low-income people with HIV.
• Effective Practices for Preventing Sexual Harassment: Universities and other entities that receive federal financial assistance (recipients) from HHS are required to administer their education and student health programs in environments free of sex discrimination, which includes sexual harassment as a form of sex discrimination.  Recipients of HHS funds are also responsible for ensuring that their sub-grantees and contractors administer their programs in an environment free from sex discrimination and sexual harassment
• Health Center Program: Health centers are community-based and patient-directed organizations that deliver comprehensive, culturally competent, high-quality primary healthcare services to the nation’s most vulnerable individuals and families, including people experiencing homelessness, agricultural workers, residents of public housing, and veterans.  Health centers serve one in 11 people across the country, and they lead the nation in driving quality improvement and reducing healthcare costs for America’s taxpayers.
• HHS Initiative to Improve Maternal Health: Summarizes the Department’s work to ensure the United States is one of the safest countries in the world to give birth.
• Housing and Services Resource Center: The Housing and Services Resource Center was created for people who work in the organizations and systems that provide housing resources and homelessness services, behavioral and mental health services, independent living services and other supportive services, and others who are working to help people live successfully and stably in the community.
• IHS Strategic Plan FY 2019–2023: Goal 1: To ensure that comprehensive, culturally appropriate personal and public health services are available and accessible to American Indian and Alaska Native people.  Goal 2: To promote excellence and quality through innovation of the Indian health system into an optimally performing organization.  Goal 3: To strengthen IHS program management and operations.
• IMPROVE Initiative: In response to rising U.S. rates of pregnancy-related deaths, or maternal mortality, NIH launched the Implementing a Maternal health and Pregnancy Outcomes Vision for Everyone (IMPROVE) initiative.  The initiative supports research to reduce preventable causes of maternal deaths and improve health for women before, during, and after delivery.
• National Breast and Cervical Cancer Early Detection Program: CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) seeks to strengthen public health and the healthcare collaboration in efforts to prevent breast and cervical cancer and address disparities.
• National Community Health Aide Program (CHAP) Implementation: The Community Health Aide Program (CHAP) is a multidisciplinary system of mid-level behavioral, community, and dental health professionals working alongside licensed providers to offer patients increased access to quality care in rural Alaskan areas.  In 2016, IHS consulted with tribes on expanding the program, and in 2018, formed the CHAP Tribal Advisory Group (CHAP TAG) to expand CHAP to the lower 48 states.
• Occupational Health Equity Program: Promotes research, outreach, and prevention activities that reduce health inequalities for workers who are at higher risk for occupational injury and illness as a result of social and economic structures historically linked to discrimination or exclusion.
• Oral Health in America: Advances and Challenges: The report updates the findings of the seminal 2000 Oral Health in America: A Report of the Surgeon General and highlights the national importance of oral health and its relationship to overall health.  It also focuses on new scientific and technological knowledge—as well as innovations in healthcare delivery—that offer promising new directions for improving oral healthcare and creating greater equity in oral health across communities.
• Perinatal Quality Collaboratives (PQCs): CDC supports 13 state PQCs through state health departments as well as a National Network of Perinatal Quality Collaboratives that supports all states.  PQCs are state or multi-state networks of teams working to improve the quality of care for mothers and babies.
• Reducing Inequities in Cancer Outcomes through Community-Based Interventions on Social Determinants of Health: CDC is launching a new cooperative agreement to conduct evaluation research to build an evidence base of innovative, community-based interventions across multiple social determinants of health to reduce racial and ethnic disparities related to cancer outcomes.
• Rural Action Plan: In acknowledgment of rural health disparities, the foundation of the Rural Action Plan is based on the following Four-Point Strategy: 1. Build a Sustainable Health and Human Services Model for Rural Communities by empowering rural providers to transform service delivery on a broad scale; 2. Leverage Technology and Innovation to deliver quality care and services to rural communities more efficiently and cost-effectively; 3. Focus on Preventing Disease and Mortality by developing rural-specific efforts to improve health outcomes; 4. Increase Rural Access to Care by eliminating regulatory burdens that limit the availability of needed clinical professionals.
• School Dental Sealant Program: School dental sealant programs effectively reach high-risk children and prevent cavities.  School sealant programs are especially important for children from low-income families, who are less likely to receive private dental care.  These programs target schools that have a high percentage of children eligible for free or reduced-cost meal programs.
• Social Determinants of Health and Equity Report to the Secretary: This report from the Physician-Focused Payment Model Technical Advisory Committee, staffed by ASPE, summarizes key recommendations and findings related to addressing social determinants of health as a key tool in improving health equity.
• Surgeon General’s Call to Action to Improve Maternal Health: Outlines strategies and actions for a diverse set of external stakeholders to improve maternal health.
• Think Cultural Health: Through this initiative, the HHS Office of Minority Health offers online continuing education programs and other resources to promote awareness and implementation of culturally and linguistically appropriate services and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care among health professionals, health organizations, and students.
• Viral Hepatitis Networking, Capacity Building: This cooperative agreement will support projects to increase in the identification of people with chronic hepatitis B and hepatitis C infection.  CDC has awarded funding to three partners (Hepatitis B Foundation, NASTAD, and University of Washington). 
• Questions Are the Answer: A public education initiative to highlight the vital role patients and families can play as part of their own healthcare teams.