Provider Spotlight: Using Data to Address Disparities

By: Dr. Susan Beane, Executive Medical Director, Healthfirst

By: Dr. Debbie Salas-Lopez, Senior Vice President, Community and Population Health, Northwell Health

Since our founding 30 years ago, Healthfirst’s members have benefited from our close relationship with health system and provider partners. We cannot solve the greatest challenges facing our members and our community on our own — and we’ve proven that working together is the best way to meet the needs of New Yorkers.

In that spirit, we’ve invited our partners to highlight the work they do to improve the well-being of the people we jointly serve, with a particular focus on health equity initiatives. While this topic came to the forefront for many healthcare organizations in response to the pandemic, combatting health inequity is something Healthfirst and our partners have been committed to for decades.

Our first guest post explores two unique data-driven efforts at Northwell Health: Providing equitable access to care and identifying individuals’ unmet needs. We’re pleased to have Dr. Debbie Salas-Lopez, senior vice president of community and population health for Northwell Health, share her perspective on these initiatives.

Working with community groups to expand vaccine access

In the early days of the pandemic, Northwell led efforts to bring COVID-19 testing to Long Island. The same was true when vaccines rolled out; the health system has administered more than 700,000 doses to date. Newsday hailed the effort, with one public health official saying, “I want to know what Long Island did right so that we can try and replicate that in other areas that are diverse.”

Northwell succeeded by going directly to the communities hardest hit by the virus. This approach relied heavily on data. First, we identified ZIP codes with the highest need for vaccines based on factors such as non-white populations, Medicaid utilization, and the Social Vulnerability Index. Then, we found community-based resources in these ZIP codes, whether it was licensed care providers (such as nursing homes and pharmacies) or groups and locations with the ability to reach large groups of people (including shopping malls, schools, sports arenas, and faith-based organizations).

Through this data-driven approach, we set up 123 vaccination sites where the need was greatest. The impact was almost immediate: The predominantly Black and Latino neighborhoods where Northwell established mobile vaccinations sites saw a 4% increase in vaccination rates in the first two weeks, compared to 2.9% in other neighborhoods. Now, we’re building on this momentum to address four key areas of health equity — education, economic vitality, the physical environment, and health disparities — in collaboration with faith-based organizations, federally qualified health centers, high schools, and various social service agencies. Since its inception to end of 2022, Northwell has provided 713,176 vaccine doses at 1,150+ faith-based and pop-up locations throughout all our service areas. More than half of these doses have been administered to community members in target areas with greatest social needs.

Bringing data from social need screening to the community

The COVID-19 pandemic brought to light for many the close relationship between social needs and overall well-being. Northwell Health providers have been screening patients for unmet social needs for the last several years, as we know social determinants of health account for about 80% of healthy outcomes.

Northwell providers screen patients for unmet social needs at 13 of our hospitals and outpatient clinics. To date, providers have screened close to 600,000 patients. This helps us at the patient level, as care teams can better identify individual needs and refer patients to the right organizations for things like food assistance, utility payments, or transportation.

There’s also a business case for screening, as it helps to fulfill regulatory requirements for the Centers for Medicare & Medicaid Services inpatient prospective payment system, for accreditation from The Joint Commission, and for National Committee for Quality Assurance recognition.

Northwell takes things one step further, however. With data available from hundreds of thousands of screenings, we can drill down to the ZIP code level and see which needs are most prevalent in which neighborhoods. This lets us enter the community as a true partner by showing community-based organizations where their resources are likely to have the greatest impact.

Northwell Health’s success in identifying unmet social needs and in deploying COVID-19 vaccinations to the neighborhoods that needed them most show that small efforts can make a major difference at the individual and community level. It also reflects the importance of partnership in delivering care to underserved populations, which is a cornerstone of Healthfirst’s mission.