Health Equity Disparities

Health Equity: A Systemic Approach

We have so much learned knowledge and have amassed incredible amounts of health data. The challenges are wrapped around how to effectively use what we know and applying this knowing to improve the outcomes of those being served within human-services. There have been so many advances in technology which we use everyday of our lives. Whether is the smart phone, tablet or laptop, they have all had an impact on how we spend time, interact with others and make purchases.

What is health equity?

Health equity is the idea that all people deserve equal access to health care. Health equity is a term that has been used to describe the idea of creating an equitable society where all people have access to health care regardless of socioeconomic status, race, ethnicity, and gender. Health equity can only be achieved when we consider the Social Determinants of Health (SDoH) alongside care. While access to care is essential to reach health equity, there are many factors upstream which must be addressed before everyone can utilize access to care to meet their health needs. SDoH factors, including access to education, neighborhood resources, community context, and economic stability, mediate a person’s ability to truly benefit from the health care they might access or receive.

What system factors prevent health equity?

Besides SDoH, there are many mutable system factors that prevent us from achieving health equity, but here are three that I feel are high up on the list.

1. Siloed data systems.

The disconnect with technology and human-services, especially connected to mental or behavioral healthcare, seems to be that information is obtained and stored but rarely connected to the work. Instead, data is just collected only to sit in the abyss of electronic bytes or files.

2. Lack of a systematic approach to apply what we learned through studies.

I bet many, if not all of you had heard out the Adverse Childhood Experiences or ACEs longitudinal study and its implications. The ACES study identified that childhood trauma had a significant impact on adult physical disease, such that more traumatic experiences, or ACES, were associated more disease states, such as diabetes and heart disease. However, this ground-breaking data sharing is only the tip of the preverbal iceberg as it relates to the mass of knowledge we know about the human experience called life.

3. Lack of strength focused care.

There is great work being by the Center for the Study of Social Policy (CSSP), where their mission is ‘Ideas in Action’ dating back to 1978. CSSP’s research-informed approach is focused around increasing family strengths, enhancing child development while reducing the likelihood of child abuse and neglect. The strength-based approach focuses on engaging systems (families, programs & communities) in building 5-key factors including parental resilience, social connections, knowledge of parenting/child development: access to concrete supports and social and emotional competency.

Why not just say ‘systems of care’ instead?

There is a real distinction between a systemic approach and systems of care. First let’s start with an understanding of what ‘systems of care’ is and its focus. System of care is a philosophical approach towards care planning.

Georgetown University’s Technical Assistance Center offers a definition and philosophy of system of care as:

A spectrum of effective, community-based services and supports for children and youth with or at risk for mental health or other challenges and their families, that is organized into a coordinated network, builds meaningful partnerships with families and youth, and addresses their cultural and linguistic needs, in order to help them to function better at home, in school, in the community, and throughout life.

What is systematic theory?

Systemic theory or general systems theory dates back to the early 1950s, with the pioneering work General System Theory Foundations, Development, Applications by Ludwig von Bertalanffy at the University of Alberta in Edmonton, Canada. (I have an original copy and I encourage everyone to give a peruse.) This theory is often used to inform family-based interventions relates to the general science of ‘wholeness.’ It can be utilized for scientific study when there is concern for the ‘organized whole.’ The family is something more than simply a collection of individuals.

What are the goals of general system theory?

The significance of general systems theory as outlined by von Bertalanffy is a scientific attempt to bridge the gap between probabilities and outcomes. It theorizes the probability in a scientific manner concerning the likelihood of subsequent events happening.

Von Bertalanffy outlined the goals or aims of general system theory.

  • General tendency towards integration in the various sciences, natural and social.
  • Integration centered in a general theory of systems.
  • Theory may be an important means for aiming at exact theory in the non-physical fields of science.
  • Developing unifying principles running ‘vertically’ through the universe of the individual sciences, this theory brings us nearer to the goal of the unity of science.
  • Leads to a much-needed integration in scientific education.

What is a systemic approach to Health Equity?

A systemic approach to health equity is a collaborative effort that aims at improving the care system and its access for all people, equally. There are ways that the system can change to meet the needs of the people it serves more effectively. Thereby the system can help meet each person where they are at and move the needle towards health equity.

A systemic approach to health equity is a process of developing a more equitable and sustainable system of care for all people. It has been developed by the World Health Organization (WHO) so that healthcare can be provided to the entire population, regardless of age, gender, ethnicity or socioeconomic status.

What is a tool to implement a systems approach to health equity?

Tools to help implement a systems approach to health equity include the use of care coordination tools, such as those that promote access to care and shared decision-making. One set of tools that can be used to operationalize this approach are those from the Praed Foundation, in their model called Transformational Collaborative Outcomes Management (TCOM).

What is Transformational Collaborative Outcomes Management (TCOM)?

TCOM espouses the concept that developing shared meaning between care team and people in care is part of the work that supports health equity. Care teams that use a TCOM approach use a communimetric approach (an method to communicate in a systematic way) for shared decision-making and care coordination.

The Praed Foundation defines TCOM as: “It is an approach grounded in a philosophy of a single shared vision–helping people achieve their health and wellness goals as they navigate healthcare, child welfare, juvenile justice, behavioral health, education, and other complex systems.”

How does TCOM address barriers to health equity?

TCOM uses communication, structured measurement and coordination to help people access, navigate, and succeed in care. A TCOM approach addresses many of the challenges of health equity because it promotes communication across siloed data systems. It helps us identify what is working for whom in care in a systematic way. This fosters an evidence-base in practice that can be communicated and distributed across systems with a shared language about outcomes achieved with specific practices in the context of individual’s lives. All structured tools of TCOM incorporate strength and skill building along side the resolution of symptoms and needs, which promotes resiliency in the context of a person’s interests, talents, preferences and spirituality.

How can I operationalize a TCOM approach to health equity?

In many ways the TCOM and its tools, the Child and Adolescent Needs and Strengths (CANS, the child/adolescent version of the communimetrics approach): Adult Needs and Strengths Assessment (ANSA, the adult version of the communimetrics approach) and the Family Advocacy and Support Tool (FAST, the family version of the communimetrics approach) align with the foundational definition of a system. As outlined by Ludwig von Bertalanffy almost 40 years ago, a system must consist of four distinct components.

What are four components for systemic health equity?

Considering this definition of a system, health equity lies at the intersection of physical/physiological, psychological, social/emotional and environmental/ communal. Like the four components of a system, systemic health equity must include basic tenants ensuring whole-person care.

  1. Physical/Physiological needs are often called basic needs, like food, shelter, safety). However, many experience a lack of essential needs Included in the absence is often access to adequate health care in support preventive/well-being care.
  2. Psychological needs relate to the inner-self or broadly conceptualized as mental health. It is not simply the absence of mental illness. The World Health Organization explicitly defines mental health as a state of well-being in which an individual realizes their own potential, can cope with the ‘normal’ stresses of life, can work productively, and they are able to contribute to their community.
  3. Social/Emotional needs are skills connected with meaningful interactions had with others, who may be part of family circles, friends or larger community. Understanding that these needs help us manage our emotions, build healthy relationships, and feel connected to the world.
  4. Environmental/Communal needs relate to the safe/nurturing physical environments, where a person lives, works, and connects with others.

These four components for systemic health equity align with Maslow’s hierarchy of needs but must include inter-dimensional relationship with a society’s structural functioning. A simple way to explain this would be that individuals are not just ‘on’ the world, they are ‘in’ the world and are impacted. Also, being ‘in’ the world impacts all four of these 4 health dimensions. We know that within society there have been inequities, especially marginalized group included black, indigenous and people of color (BIPOC), communities and access to quality healthcare and education.

Why is whole person care important for health equity?

This is important for health equity because it allows the person to be able to participate in their care, which gives them a more holistic approach. Additionally, this type of care allows for person-centered care, which is important for patient empowerment.

So, our work with and individual (child/adolescent or adult) can and should be viewed from a systems perspective, especially using the TCOM tools. Isn’t this is the whole purpose behind both understanding the person with-in-environment definition, especially identifying their needs and strengths and those of their caregiver(s)/parent(s) using the CANS? For example, the FAST has a domain generally referred to as the ‘Family Together’ to help tell the story of the family system above and beyond the stories of the individual family members. Therefore, those being assessed are more fully being viewed as a physiological, psychological and socio-cultural-behavioral beings, living within a larger cultural system, connected to a family of origin.

Why is context important for health equity?

For the system to move toward health equity, it must meet a person where they are at. That means that care planning should consider the context of the person’s life and their ability to carry out that plan. Cookie cutter care plans that recommend the same diet, exercise and mindfulness for everyone don’t take into consideration access to high quality food in their neighborhood, size of their home or proximity to a safe place to exercise, or other stressors in life that currently prevent organized thinking for the person.

When using either of these tools and charting the child/youth’s or family’s needs and strengths, shouldn’t this be done within the framework of that individual’s family, school and community context? For example, the ANSA charts the adult needs and strengths within the context of that individual’s family of origin, current family constellation, work and community. If this is so, then wouldn’t it make sense to utilize systemic theory to assist in the diagnosing and treatment of those being assessed? This really is the complete definition of whole person-centered care. An absolute essential need for health equity as it relates to social determinants of health in my opinion.

How can we tell if health equity has been achieved?

Achieving health equity will not happen overnight. We cannot achieve health equity until there are changes in the healthcare system that ensure that all Americans have access to high-quality resources and services regardless of their socioeconomic status. We can make incremental changes to the system that increase accessibility, affordability, and adequacy of opportunities for good health for all. In the figure below, we can see that 23% of American Indian and American Native people self-report poor or only fair health. This compares to 10% of White Americans. Approximately 15% of African Americans and Latinx Americans report low or poor health. When we make impactful and incremental changes to the system to increase health equity, these health disparities will begin to reduce and eliminate.

My Work

I have been a part of the world-wide TCOM Collaborative for more than 15 years. My formal clinical training has been in family systems, specifically in multi-generational family therapy or Bowenian family therapy. I recall presenting at an event and began to discuss the CANS and other TCOM Tools with family therapists. Several marriage and family therapists (MFTs) continue to this day to contact me regarding CANS/TCOM and how they can be used as part of developing individualized whole person-centered care planning. I have shared with them how I incorporate them in my work with children/youth and families in my practice and how treatment planning has been significantly more successful. It is my sincere belief that both TCOM and its associated tools should be brought directly to those who are serving in ever human-service sector (e.g. primary health care). They are quite simply standards of effective practice.

*von Bertalanffy, L. (1968). General System Theory Foundations, Development, Applications. New York, NY: George Braziller, Inc.

Ken McGill EdS, LMFT- Opeeka’s Solution-Focused Care Senior Scientist. Served within New Jersey Children’s System of Care (NJCSOC) 17 years out of the 20 years statewide implementation. He came to Opeeka from Rutgers University-University Behavioral Health Care-Behavioral Research Training Institute serving as the statewide trainer on Wraparound, the fundamental evidence-based practice offered throughout the NJCSOC, and the Child and Adolescent Needs and Strengths (CANS) curriculum. Ken was the 2013 recipient of the Praed Foundation’s Outcomes Champion (TCOM/CANS) Award for his work in children’s systems of care and outcomes management. He has more than 20 years of experience in marriage and family therapy, education & research and was the longest serving President of the New Jersey Association for Marriage and Family Therapy (NJAMFT). [email protected]