Institutional Journey in Pursuit of Health Equity: Veterans Health Administration’s Office of Health Equity

One might wonder why the Office of Health Equity (OHE) at the Veterans Health Administration (VHA) called for a supplement dedicated to Veterans Affairs (VA) health equity research. The answer is not far-fetched if you consider the unique ability of research to inform, shape and impact the journey toward health equity. This is one of the ways the VA is joining the dialogue on health disparities in vulnerable populations. These efforts have been ongoing, as evidenced by programmatic and research initiatives focusing on rural health, women’s health, homelessness, and mental health. Yet in 2012, VHA took further steps to make health equity an institutional goal by establishing an office dedicated to health equity.

VHA has prided itself as a leader in many areas ranging from electronic health records to groundbreaking research such as telehealth.¹ It is therefore not surprising that VHA endeavors to be a leader in health equity. In fact, VHA’s actions to achieve health equity came on the wings of a more global dialogue. In 2011, governmental leaders and other representatives convened at the World Health Organization’s Rio de Janeiro conference and declared their determination to achieve social and health equity by outlining recommendations to further reorient the health industry and other sectors toward this goal.²

National efforts were also under way that provided additional momentum and synergy throughout the United States. For example, Healthy People 2020 provided a very illustrative and compelling picture of how policies, data, research, and other factors interplay to impact health equity for the United States (Figure 1).³ The Patient Protection and Affordable Care Act⁴ recognized the need to tackle health disparities as integral to improving the health of a nation with more than 60 provisions on addressing health equity.⁵ The National Partnership for Action was also convened in 2010 to mobilize various government agencies and stakeholders to achieve health equity.⁶ VA, along with other federal agencies and stakeholders, participated in these and related meetings that proposed a frame for achieving health equity.

FIGURE 1—

Action model to achieve Healthy People 2020 overarching goals.

VHA VISION FOR HEALTH EQUITY

VHA chartered a health care equality workgroup in 2011 to determine how VA could provide a more equitable health care delivery system. The workgroup’s recommendations, as well as efforts by the VA’s Advisory Committee on Minority Veterans,⁷ supported a dedicated national-level office to address this topic. In 2012, OHE was born.

The OHE is charged to ensure that VHA provides appropriate individualized health care to each veteran in a way that eliminates disparate health outcomes and assures health equity. The OHE is therefore championing the advancement of health equity and reduction of health disparities. Institutional intention to enhance health equity is built into VHA’s recent Strategic Plan. According to the goal of quality and equity, Veterans will receive timely, high quality, personalized, safe, effective, and equitable health care, irrespective of geography, gender, race, age, culture, or sexual orientation. The resultant strategy is that VHA will develop an understanding of where health and health care inequities exist, identify factors that contribute to inequities, and intervene to eliminate such inequities. This means weaving health equity into discussions at all levels of policymaking, decision-making, resource allocation, operations, and performance plans.

DEFINING AND ACHIEVING HEALTH EQUITY

In defining health disparities, and as reflected in the call for papers for this supplement, OHE casts a wider net in determining vulnerable populations. This allows us to examine health disparities along the lines of racial or ethnic group; gender; age; geographic location; religion; socioeconomic status; military era; sexual orientation; mental health; disability status including cognitive, sensory, and physical; and other characteristics historically linked to discrimination or exclusion. The VHA is the largest integrated health care system in the United States. Many access barriers to care are greatly reduced in this system, and staff share the same incentive to provide quality care to all. This presents a seemingly level playing field where disparities are greatly reduced nationally.⁸ However, more work is needed, especially at the facility level where disparities persist.

Institutional support to eliminate health disparities is evidenced through VHA’s Health Equity Coalition. The Coalition was established in 2013 as the department’s steering committee for health equity pursuits. It comprises representatives from a cross section of VA stakeholders with the OHE Executive Director as chair. An early goal of the Coalition was the development of an action plan to achieve health equity. As such, the VHA Health Equity Action Plan (HEAP) was developed to serve as a guide and starting place to address these issues.

The HEAP is considered a living document open to modification and adaptation to continuously meet the needs of the veterans. It is directly aligned with the VA and VHA strategic plans, and highlights focus areas related to similar goals developed by the National Partnership for Action to End Health Disparities.⁶ The HEAP therefore looks both inward and outward, and demonstrates alignment with other federal partners working to achieve health equity. Some highlights of the plan include:

• Awareness—Develop strategic partnerships within and outside VA, including the incorporation of the voice of the veteran;

• Leadership—Assess health equity impact for all policies, memos, handbooks, procedures, directives, action plans, and governance;

• Health System Life Experience—Incorporate social determinants of health in personalized health plans;

• Cultural and Linguistic Competency—Increase education and training on health equity, cultural competency to include unconscious bias, microinequities, diversity, and inclusion; and

• Data, Research and Evaluation—Develop common definitions and measures of disparities and inequities, and develop and implement strategies for capturing data on race, ethnicity, language, socioeconomic status, and other variables needed to stratify the results for all quality measures and to address disparities.

This plan creates a forum to incorporate innovative ideas and input of all users to encourage a bottom up approach while maintaining a strong connection to the overarching goals of the VA. Along these lines, OHE financially supported nine health equity quality improvement projects during fiscal year 2014. This effort called for project ideas emanating from the field. Funded projects are intended to address health and health care disparities pertinent to the facility-level demographics with the implementation of an intervention aimed at targeting the disparities among a select vulnerable population. Facilities were highly encouraged to partner with researchers for evaluation and impact assessment.

Similarly, in fiscal year 2013, OHE hosted a two-day health disparities think tank meeting. Researchers, data analysts, and key stakeholders working with vulnerable veteran populations provided valuable input that enhanced portions of the HEAP and sparked partnerships and collaboration among researchers and policymakers on health disparities issues. Results of some of these engagements are evident in this supplement and articles accepted for publication in several journals. Additionally, OHE serves as the nominating office and programmatic lead for a literature and evidence synthesis project focusing on primary care access for mentally ill veterans. As an ongoing effort, OHE provides substantial support for relevant research and policy initiatives, participates on steering committees and advisory councils, and provides support letter for grants. For instance, OHE currently supports evaluation of a project that seeks to reduce hypertension among minority veteran populations and another to increase the awareness of unconscious bias among clinical staff and understanding the impact of these presumptions on health care outcomes for those we serve.

CLOSING

It is time to refocus, reinforce, and repeat the message that health disparities exist and that health equity benefits everyone.

—Kathleen G. Sebelius, Former Secretary, US Dept of Health and Human Services⁹

The face of the Veteran population is changing. In fiscal year 2013, 6.5 million unique patients among the 8.9 million enrollees were treated in the VA health care facilities across the country.¹⁰ As an agency, we are aware of the changing demographics of the veterans and that we need to rethink how we provide care. Projected population demographics indicate steady increases in minority and female populations in the coming years. The number of World War II and Korean Conflict veterans is declining fast, while Vietnam Era veterans are getting older. Additionally, veterans with various disabilities are on the rise from past conflicts and drawdown of 2 recent wars.

The content of this supplement will not only highlight these trends but also show how VHA is responding. The articles show evidence as well that our understanding and interventions for some vulnerable populations are further along than for others. This supplement not only creates awareness but also stands to inform future actions in the pursuit of heath equity for all veterans.

I have attempted to chronicle the VHA institutional approach to addressing health equity. I hope this supplement assists in translating research into action. Despite the efforts to eliminate silos and other barriers that spur inequities, one might wonder why there has not been more progress in elimination of health disparities. The solutions reside in meaningful collaborations among researchers, policymakers, and the community at large. The pursuit of health equity should be everyone’s business. It is a journey that takes time and effort. What can you do today in your area of influence to improve health equity? I personally recommend—at a minimum—in all your actions, do not increase the disparity.