Rebecca Haffajee, JD, PhD, MPH

Acting Assistant Secretary for Planning and Evaluation

U.S. Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation, Strategic Planning Team
Attn: Strategic Plan Comments
200 Independence Avenue, SW, Room 434E
Washington, DC 20201

RE: Public Consultation on the Draft HHS Strategic Plan FY 2022 – 2026

Dear Dr. Haffajee,

CEO Action for Racial Equity (CEOARE) is pleased to provide input on the U.S. Department of Health and Human Services (HHS) Draft Strategic Plan FY 2022 – 2026. We commend HHS on its mission-driven commitment to enhance the health and well-being of Americans and its enhanced focus throughout the Draft Strategic Plan on underserved populations as defined by Executive Order 13985. In this letter, we seek to provide specific input on HHS strategic objectives with an emphasis on using a data-driven approach and applying a racial equity lens whereby explicit consideration is given to race and ethnicity to confirm that HHS’ health equity goals are adequately met across various social determinants of health (SDOH) metrics.

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 About CEOARE

CEOARE is a Fellowship composed of over 100 companies that mobilizes communities of business leaders with diverse expertise, across multiple industries and geographies, to advance public policy in four key areas — healthcare, education, economic empowerment, and public safety. Our mission is to identify, develop, and promote scalable and sustainable public policies and corporate engagement strategies that address systemic racism, social injustice, and improve societal well-being.

Evaluating historically underserved populations, the CEOARE Fellowship has a policy portfolio focused on eight issues that disproportionately and systemically impact Black Americans. Five of these advocacy efforts are underway in areas that specifically overlap with HHS agency authority and relate to this Draft Strategic Plan. These include: Expanding Access to Telehealth; Closing the Digital Divide; A Path Toward Greater Food Equity; Racism: A Public Health Crisis; Equity and Excellence in Early Childhood Education. Through these efforts, our vision is to improve the quality of life for the 47M+ Black Americans through advocacy and advancement of solutions that seek to end systemic racism.

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Input on HHS Strategic Objectives

 

OBJECTIVE 1.2: Reduce costs, improve quality of healthcare services, and ensure access to safe medical devices and drugs

Strategy: Partner with states and external quality measure development experts to define and encourage use of a core set of metrics to measure provider effectiveness in Medicaid, the Children’s Health Insurance Program (CHIP), and pay-for-performance programs, including reliable metrics of access to care, gaps in care, disparities, health equity, and achieving positive outcomes for all populations.

CEOARE encourages the use of disaggregated and transparent core metrics to provide insights and assess health disparities, in particular the alarming impacts of structural racism for all populations. To help address structural racism, racial equity should be a fundamental element of any core set of metrics that measures provider effectiveness. Disaggregating metrics by race and ethnicity, gender, age, sexual orientation, generational cohort, location, veteran status, disability status and all combinations/ intersections thereof will help provide the racial equity insights required to focus policy initiatives. HHS should invest in technology infrastructure in order to optimize data collection, data insights and knowledge sharing.

HHS should encourage healthcare and technology industries to collaborate and incorporate Black community health needs into core metric program and service design and should collaborate with Black community advocacy groups to bring a clear racial equity lens to the development and use of core metrics to pursue health equity.

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Strategy: Promote and support implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care by health professionals, health systems and organizations and in HHS programs to improve the quality of care and reduce health disparities by ensuring the provision of services that are respectful of and responsive to individuals’ health needs, preferences, culture, and preferred language.

CEOARE supports the implementation of national standards for culturally and linguistically appropriate services in health care. We encourage HHS to implement these services using a racial equity lens that takes into account the lived experiences of communities of color that enables fairness and justice in the investment and distribution of resources utilized to combat these unbalanced conditions.

An understanding of racial disparities must go in tandem with culturally competent health care provider training, available language translations, and investment in innovative health services. Task forces and centralized groups should be formed to improve coordination on how best to utilize resources to align with health needs and preferences while working together to identify the most critical needs of high-risk populations.

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Strategy: Implement an equity impact strategy to support data-driven quality improvement approaches to identify and address health disparities in access to, use of, and outcomes from programs and policies among underserved populations.

CEOARE supports a data-driven approach to identify and address health disparities for underserved populations, particularly Black Americans.  We encourage a specific focus on racial equity gaps as these gaps are generally far larger than any other demographic factor across all SDOH.

CEOARE encourages the use of a data analysis framework and methodology that collects and reports disaggregated data based on race, ethnicity, income, age, gender (and all intersections), to be utilized for ongoing reporting, to identify root causes of health disparities and to inform racial equity action plans. CEOARE encourages transparency in the measurement and tracking of improvement of various health, economic and social outcomes.

CEOARE specifically encourages harnessing the power of data insights by collecting and analyzing data disaggregated by the variables listed in the discussion on core metrics above.

We support establishing a permanent office and positions dedicated to health, racial equity, and anti-racism in public health that monitors, manages, and facilitates the budget, funding, data analysis, and return on investment of initiatives, while communicating results, findings, and recommendations to the community and other government entities.

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Strategy: Support research and evaluation of expanded use and availability of telehealth and telemedicine, including effects on cost, reimbursement, access, and care outcomes and harms, to inform the long-term approach to using this technology and to improve access to care for underserved populations.

CEOARE supports evidence-based decision-making and the research and evaluation of telehealth services to assess telehealth for its cost-effectiveness, and impact on health outcomes. We recommend that the Centers for Medicare & Medicaid Services (CMS) permanently maintain the Category 3 framework, providing a pathway to permanence for the telehealth services for which CMS requires additional evidence. By retaining the Category 3 framework, CMS is more equipped to gain and compare relevant information between populations- evaluating how effective telehealth is for general populations versus geographic areas of vulnerable and underserved communities.

CEOARE recommends that HHS leverage available insights related to SDOH metrics as a foundational pillar in researching and evaluating use and availability of telehealth services.

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

Strategy: 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).

CEOARE supports expanding the capacity of resource centers, healthcare organizations and the health workforce to reduce health and healthcare disparities. Specifically, CEOARE recommends that HHS focus on funding and training healthcare workers to make sure they are prepared to provide culturally responsive health literacy education and are trained to identify the impacts of the SDOH when treating patients. Additionally, full utilization and funding for community health centers that have a demonstrated history of meeting health needs of those most impacted by racial health disparities and the SDOH should be actively considered.

CEOARE recommends that HHS encourage the use of Community Health Workers and Patient Navigators, who can be valuable members of the care team to help patients navigate the complexities of the healthcare system and get connected with the appropriate resources.

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Strategy: 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.

CEOARE agrees that HHS should develop protocols and checklists that take into consideration the effects of structural racism on underserved populations while working with organizations and communities to inform protocols and any materials that are developed. Specifically, working with and through community health centers and community health workers in both the design and implementation can help to increase the rates of adoption.  The process to develop respective protocols and checklists should include input from racially diverse teams to confirm that the final product is racially equitable and responsive to the needs of underserved populations while eliminating racial bias.  Protocols, policies, procedures, and checklists should clearly define roles and responsibilities, and evaluation processes to hold organizations responsible for successful implementation.  Training and education programs (e.g., cultural competency and implicit bias) should also be developed and required for all professionals working in the clinics to promote consistency and transparency.

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Strategy: 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.

CEOARE strongly supports multi-sector action plans for addressing the SDOH and supports taking a data-driven approach to analyzing and identifying racial disparities in access to quality public education options, including enablers like broadband access and structural support like early childhood education;  public safety and trauma supports; preventative healthcare access and food equity; and economic opportunity, including access to quality affordable housing options and support for small minority-owned business development to inform funding and to determine the actions required to improve health outcomes based on resources available.

Additionally, results-driven programs and services designed and led by community-based organizations that advance improved quality of life outcomes for those most impacted by racial disparities in the SDOH should be prioritized for funding support. As part of this, CEOARE recommends the development of racial equity action plans that proactively utilize existing grants and funding programs, with clear budgets, funding requirements, goals, and timelines that prioritize preventive measures that invest in the SDOH to significantly reduce reactive care and costs. Research and data demonstrate that investment in the SDOH, like food equity and housing, has incredible returns on investment by significantly reducing healthcare costs (e.g., by 300%).[1]

1. Policymakers should acknowledge and address the adverse health effects of structural racism as well as root causes of racial disparities to improve SDOH. This includes investment in cultural competency and implicit bias training within HHS to help foster a better understanding of the role that structural racism may play in determining health outcomes to help guide solutions the agency may develop and advance.
2. Healthcare professionals and social workers should also be trained, funded, and directed to screen patients for disparities related to the SDOH.

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Strategy: Support research on telehealth to answer questions related to how it affects access to care and the quality and cost of care, including for underserved populations.

CEOARE recommends that HHS evaluate the effectiveness of telehealth for disease management from both the patient and provider perspective. Ensuring the delivery of equitable, high quality, clinically appropriate care is a priority for CEOARE. Thus, we urge HHS to consider the value of provider-patient decision-making with regards to determining the appropriateness of telehealth use as opposed to federally imposed restrictions. We also suggest that this research represents the experiences of individuals across socio-economic, racial/ethnic, geographic, and other demographic factors.

CEOARE recommends additional research on the following:

1. Evaluation of the impact of in-person requirements for telehealth services on access to care for vulnerable and underserved communities
2. Evaluation of how the definition of “home” as an originating site, now inclusive of temporary lodging, impacts access to care for vulnerable and underserved communities.
3. Evaluation of the effectiveness of audio-only telehealth services for disease states and services beyond mental/behavior health
4. Assessment of the appropriateness for continued coverage of audio-only telehealth services beyond the Public Health Emergency to ensure access of care for this vulnerable population, with specific attention on underserved populations impacted by the digital divide
5. Evaluation of the impact on access to care for vulnerable and underserved populations when telehealth is furnished via Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

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Strategy: Deliver safe, affordable, accessible, quality, value-based primary healthcare to underserved populations through health centers and other community providers.

CEOARE encourages HHS to collaborate with those providing healthcare services in the communities most impacted by racial health disparities (e.g., community health workers, community health centers, and community care advocates), and support advanced training to foster stronger communication and trust to help meet the needs of underserved communities. CEOARE encourages HHS to collaborate with other subject matter experts experienced in working within underserved and under-resourced communities to explore ways to include culturally competent social risk factors in risk adjustment methodologies used in outcomes-based and value-based models to ensure that providers who serve a population with disproportionately higher SDOH needs receive the appropriate support and resources necessary for serving that population. Current risk adjustment methodologies do not recognize the distinction between poor quality of care and high social risk, which can inappropriately penalize providers who care for patients with SDOH.

HHS should consider promoting alternative payment models for services provided through community health centers that offer an incentive structure for health care delivery that more closely aligns with centering patient outcomes and quality, reducing the cost of care, and improving population health compared with fee-for-service payment structure. Innovation and technology continue to rapidly evolve, and we encourage HHS to amplify and support pathways towards innovative interventions that improve patient outcomes and reflect value-based care that address known health disparities and SDOH.

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OBJECTIVE 1.4: Drive the integration of behavioral health into the healthcare system to strengthen and expand access to mental health and substance use disorder treatment and recovery services for individuals and families

Strategy: Increase equitable access to care, including bi-directional integration, where physical and behavioral health providers coordinate and deliver care, and expand telehealth options.

CEOARE supports telehealth services for mental health and substance use disorder treatment and recovery to increase equitable access to care and integration of physical and behavioral health services. The COVID-19 pandemic highlighted the unattended mental health[2] crisis in the US – only 10% of Americans with a mental health disorder get effective treatment, and treatment rates are lower for Black Americans.[3] Additionally, the traditional approach of treating mental and behavioral health separately from physical health leads to suboptimal care.[4] Telehealth has the potential to support equitable access and integrated care.

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OBJECTIVE 1.5: Bolster the health workforce to ensure delivery of quality services and care

Strategy: Partner with states, Federal Qualified Health Centers, clinics, schools, other community-based organizations and the private sector to ensure the health workforce is appropriately and adequately trained with culturally-competent, evidence-based strategies and education modules for addressing systemic bias and racism, ableism, and transphobia to reduce health disparities in the communities they serve.

CEOARE supports the above collaborative relationships to help healthcare providers and those interfacing with patients receive culturally relevant and responsive training to support positive health outcomes. CEOARE recommends that these efforts include funding support for participating in racial equity coalitions, alliances, and collaborative networks to share data and reporting, measurable outcomes, key learnings, leading practices, and educational materials (including those that help educate and provide people with access to wellness check-ups, healthy food options and the tools to increase their understanding of how to monitor one’s own health metrics) to increase and sustain overall impact.

Other actions HHS should consider include implicit bias training for all healthcare workers and educating health professionals on SDOH and how issues such as exposure to poor air quality, food insecurity and unstable housing (among others) can impact health outcomes.

CEOARE also suggests that HHS consider utilizing a framework for training the health workforce, such as the Racism as a Root Cause (RRC) approach,[5] which is based on four principles that should be considered as part of the implementation, training, and education processes:

1. Prioritize specific, racialized groups for a precise, rather than universal, impact.
2. Work to change policies, systems, or environments, as opposed to changing people.
3. Be institutionalized and sustainable to create a long-term impact.
4. Repair historical injustices by shifting resources, power, and opportunities to racially marginalized groups.

 

OBJECTIVE 2.1: Improve capabilities to predict, prevent, prepare for, respond to, and recover from emergencies, disasters, and threats across the nation and globe

Strategy: Ensure that HHS is prepared to make effective use of available waiver options and systems in place to expand and maximize flexibilities when a public health emergency is declared, ensuring response efforts can scale to readily support communities.

CEOARE supports the telehealth flexibilities provided by HHS during the COVID-19 public health emergency (PHE), which have been critical to providing equitable access towards Medicare beneficiaries. While we support permanent coverage of expanded telehealth flexibilities, particularly, the removal of geographic eligibility requirements and originating site restrictions, CEOARE recommends that services provided via waivers are evaluated for effectiveness, utilization, and disparities to inform which services should be retained following a PHE. In addition to these permanent measures, CEOARE encourages HHS to incorporate digital tools and telehealth into PHE readiness plans in order to be able to quickly respond to the needs of underserved communities during a future PHE.

 

OBJECTIVE 2.3 Enhance promotion of healthy behaviors to reduce occurrence and disparities in preventable injury, illness, and death

Strategy: Support and improve the dissemination and accessibility of information and interventions related to physical activity, healthy eating, food deserts, food insecurity, nutrition, and nutrition labeling to reduce the incidence of related health conditions and chronic diseases.

CEOARE encourages holistic evaluation and consideration of the variables that enable (or deter) communities from being able to access, afford, and prepare healthy food and exercise healthy habits. SNAP-Ed, [6] for example, is a reliable program to educate recipients on how to access and prepare healthy meals; nevertheless, it is reasonable to conclude that many participants of the SNAP (Supplemental Nutritional Assistance Program) program lack the technology or resources needed, such as: smartphones or access to internet, to take advantage of this educational tool.[7]^,[8]

CEOARE encourages HHS to work in collaboration with the USDA (United States Department of Agriculture) Federal and Nutrition Services to:

• Improve coordination and collaboration between SNAP, Medicaid, Medicare, and food equity experts to improve food access, nutrition, and diet related health outcomes – focusing on nutrition for Medicaid recipients, which often involve child nutrition and development as well.
• Collaborate across congressional agriculture and health committees to better align SNAP, Medicaid, Medicare, and other federal programs to reduce the complexity of program participation as well as the health of participants.
• Align programs and data collection and transparency related to food and nutrition across the USDA and other federal agencies.
• Reduce barriers to sharing data and coordinating outreach across state-administered federal programs.
• Adopt modern technologies for state program administration.[9]

Strategy: Partner with states, tribes, local, and territorial communities, including private and non-profit organizations, to expand tailored prevention education and interventions to reduce health disparities, focusing efforts in addressing disparities in injury, substance use and misuse, illness, morbidity, and mortality rates in underserved populations. 

CEOARE supports the expansion of tailored prevention education and interventions to reduce health disparities. Specifically, CEOARE advises HHS to create education and training programs, materials, media, and forums to expand the understanding — on both the organizational and individual levels — of the impacts of racism and historical oppression, and how to implement actions that increase racial equity.

CEOARE also recommends that HHS encourage and support healthcare workers in the implementation of educational programs designed to promote health literacy and an understanding of solutions that can holistically address the SDOH (e.g., food equity, housing, education).  Additionally, healthcare workers should be incentivized to develop and cultivate relationships with individuals and organizations that facilitate SDOH programs and funding, so they can make trusted and appropriate connections between patients and those organizations. Related to that, HHS should encourage healthcare workers to provide prevention education around nutrition, stress management and mental and physical health.

 

OBJECTIVE 3.2: Strengthen early childhood development and expand opportunities to help children and youth thrive equitably within their families and communities.

Strategy: Improve access to stable and affordable high-quality early care and education settings and participation in early childhood programs of underserved communities and populations and the replication and application of lessons learned from successful programs focused on inclusion practices.

CEOARE recommends that HHS apply a racial equity lens and address educational disparities by providing additional resources and infrastructure to underserved and/or low-income communities where the achievement gap continues to increase. Specifically, we ask that HHS implement a provision requiring states to use a significant percentage of the Child Care Development Block Grant Fund (CCDBGF) to address educational disparities in underserved and low-income communities. We believe that a more targeted approach is necessary to address issues of inequity if we are to close the achievement gap.

CEOARE recommends the assignment of dedicated funding to help states improve tracking of the racial equity data for programs such as CCDBGF, Head Start, and Preschool Development Grants Birth through Five (PDG B-5), so that they can better determine in which communities the inequities exist and implement more targeted measures to address the same.

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Strategy: Invest in early childhood development, learning, and care by building the capacity of the staff and workforce supporting the programs and services provided to children and families in these sectors, including programs serving low-income communities and populations.

CEOARE encourages enhanced job training for early childhood professionals and competitive wages. We ask HHS to consider a targeted approach that prioritizes training, upskilling, and retaining early childhood education workers in programs such as Head Start that serve communities with the greatest need. This will not only serve to help build the capacity of the early childhood education workforce, but it will also directly impact the quality of the education and the educational outcomes.

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Strategy: Stabilize the early care and education sector to address decreased revenues and increased costs resulting from the COVID-19 pandemic and build back a high-quality supply of programs and providers, particularly in low-income communities.

CEOARE encourages investments specifically designed to increase the number of early childhood education providers and facilities in underserved communities and support upgrades and improvements to the physical infrastructure of childcare facilities in such communities that will positively impact the development of young children and bring existing facilities up to professional standards.

CEOARE encourages further funding support of early care and education providers to stay open or reopen and provide a safe and healthy learning environment for children, especially those in underserved communities.

CEOARE also encourages HHS to conduct a review of its policies to make sure they support a mixed-delivery system that includes services and programs offered via a variety of programs and providers with flexible choices for parents and caregivers that all accomplish positive outcomes for their children.[10]

 

OBJECTIVE 3.3: Expand access to high-quality services and resources for older adults and people with disabilities, and their caregivers to support increased independence and quality of life

Strategy: Support healthcare partners, state, community, profit, and non-profit organizations to expand infrastructure related to needs of older adults, persons with disabilities, and caregivers and improve coordination and communication of resources and services such as in-home services, transportation, digital equipment, broadband access, and healthcare to meet the day to day and long-term needs of older adults, persons with disabilities, and caregivers. 

CEOARE acknowledges the value of telehealth as a tool to deliver healthcare services for older adults and those with disabilities, across all modalities. Telehealth enables healthcare access for patients with barriers to care such as those with limited mobility or lack of access to transportation, and those residing in areas with provider shortages. Additionally, telehealth has the potential to improve caregiver engagement and reduce caregiver burden.[11]

CEOARE supports broadband and end-user technology expansion policies targeting the digital divide, with special focus on policies that promote equitable access, affordability and use of telehealth services and technology. A targeted approach will be needed to make sure that needs of older adults, people with disabilities and their caregivers are met.

 

OBJECTIVE 4.4: Improve data collection, use, and evaluation, to increase evidence-based knowledge that leads to better health outcomes, reduced health disparities, and improved social well-being, equity, and economic resilience

Strategy: Better engage and include community stakeholders and those with lived experience into the policymaking, program improvement, and research processes.

CEOARE recommends targeted engagement with underserved communities, especially Black communities that experience disproportionately high rates of adverse health outcomes. Targeted engagement with a racial equity lens will make sure that solutions are made with the target audience as a focus.

CEOARE also believes that a focus on health literacy will confirm that the healthcare resources are appropriately adopted by all members of underserved populations, including those in the Black community.

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Strategy: Integrate social determinants of health data into surveillance systems, electronic health records, clinical decision supports, and other data collection points to improve knowledge and ensure equitable access to quality care and service delivery.

CEOARE encourages HHS to improve data collection on race and ethnicity, as well as disparity variables such as preferred language, tribal identity, disability status, sexual orientation, gender identity, socioeconomic status, social, psychological, and behavioral health factors. These metrics are the foundation for identifying and addressing health disparities and unmet social needs.^[12]

CEOARE recommends HHS drives a standardized process across the different agencies for collecting meaningful patient data, especially focused on disparity variables. Although robust demographic data collection is often cited as a critical component for reducing health disparities,^{[13],[14],[15]} opportunities to maximize data collection through policy must improve.^[16],[17]  Enhancing the quality of race and ethnicity data to reflect self-identification more closely is critical as populations and communities are complex and addressing health disparities and SDOH should have targeted approaches to address the needs of those communities.

Specifically, we believe fundamental components that must be considered in this process include:

• Standardization of collecting and reporting SDOH data
• Standardization of collecting and reporting race and ethnicity data
• A framework for building trust with individuals related to data use
• Self-reported data from individuals as the gold standard
• Policies to protect data privacy, security, governance, and ownership
• Standardization of SDOH data sharing and exchange
• Consideration for provider burden.

 

Conclusion

As HHS considers strategic activities to reach its objectives over the next five years, we urge the Department to advance and integrate data sharing and collaboration across its agencies and offices and relevant external partners. Additionally, in furtherance of HHS’ enhanced focus on underserved populations, we suggest HHS consider a collaborative and integrative approach to evaluating the impact of structural racism within individual agencies and offices and the impact on underserved communities. As the compounding effects of structural racism have been brought to new light by the COVID-19 pandemic, HHS stands in a unique position to coordinate key agencies to standardize data, identify need, and distribute resources to significantly improve health equity and address the needs of underserved populations.

Thank you for your leadership, and for the opportunity to provide input the Draft HHS Strategic Plan FY 2022 – 2026. If you have questions, please do not hesitate to contact Roz Brooks via email at Roslyn.g.brooks@ceoactionracialequity.com.

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Sincerely,

CEO Action for Racial Equity

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Citations

[1] Susan Morse, “What Montefiore’s 300% ROI from social determinants investments means for the future of other hospitals”, Healthcare Finance, July 5, 2018
[2] Megan Leonhardt, What you need to know about the cost and accessibility of mental health care in America, CNBC, May 10, 2021
[3] Nicole Chavez, American Psychological Association apologizes for contributing to systemic racism, CNN, November 1, 2021
[4] PRWeb , NEJM Catalyst Insights Report: Mental and Behavioral Health Services Inadequate to Meet Patient Population Needs, February 16, 2018
[5] Zea Malawa, Jenna Gaarde, and Solaire Spellen, “Racism as a Root Cause Approach: A New Framework”, Pediatrics Jan 2021, 147 (1) e2020015602; DOI: 10.1542/peds.2020-015602
[6] SNAP-Ed Connection
[7] Heather Hahn, Rayanne Hawkins, Alexander Carther, and Alena Stern, Access for All: Innovation for Equitable SNAP Delivery, Urban Institute, June 2020
[8] Emily Vogels, Digital divide persists even as Americans with lower incomes make gains in tech adoption, Pew Research Center, June 22, 2021
[9] Bipartisan Policy Center, Leading with Nutrition: Leveraging Federal Programs for Better Health, March 2018
[10] National Education Association, How ESSA impacts early childhood education, July 2020
[11] Li-Chi Chiang, Wan-Chou Chen, Yu-Tzu Dai, Yi-Lwun Ho, The effectiveness of telehealth care on caregiver burden, mastery of stress, and family function among family caregivers of heart failure patients: a quasi-experimental study, National Library of Medicine, May 24, 2021, PMID: 22633448 DOI: 10.1016/j.ijnurstu.2012.04.013
[12] Institute of Medicine (US) Subcommittee on Standardized Collection of Race/Ethnicity Data for Healthcare Quality Improvement, Cheryl Ulmer, Bernadette McFadden, David R. Nerenz, Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement, National Academy Press; 2009.
[13] Agency for Healthcare Research and Quality, Advancing Excellence in Health Care, 2012 National Health Care Disparities Report, 2013, Pub No. 13- 0003
[14] Joint Center for Political and Economic Studies, Patient Protection and Affordable Care Act of 2010: Advancing Health Equity for Racially and Ethnically Diverse Populations, July 2010
[15] Health Research & Educational Trust, Reducing health care disparities: Collection and use of race, ethnicity and language data, August 2013
[16] Megan Daugherty Douglas, JD, Daniel E. Dawes, JD, Kisha B. Holden, PhD, MSCR, and Dominic Mack, MD, MBA, Missed Policy Opportunities to Advance Health Equity by Recording Demographic Data in Electronic Health Records, Am J Public Health, July 2015, 105 Suppl 3:S380-8. doi: 10.2105/AJPH.2014.302384, PMID: 25905840; PMCID: PMC4455508
[17] Department of Health and Human Services, Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status, October 2011