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Featured topic and speakers
What is inclusion in health care? How does the cocoon pregnancy care model work? Why is holistic care important? How do you provide holistic health care?
Our guest is Nkem Chukwumerije, MD, MPH, executive sponsor for equity, inclusion and diversity for the Permanente Medical Groups. He is also the president and executive medical director for the Southeast Permanente Medical Group. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Nkem Chukwumerije, MD, MPH, executive sponsor for equity, inclusion and diversity for the Permanente Medical Groups
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're focusing on the importance of inclusion and the role it plays in delivering equitable care to patients. Our guest today is Dr. Nkem Chukwumerije, national physician lead for Equity, Inclusion and Diversity for the Permanente Medical Groups. He's also the president and executive medical director for the Southeast Permanente Medical Group. And he's calling us today from Atlanta, Georgia.
I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Chukwumerije, welcome.
Dr. Chukwumerije: Yeah. Thank you, Todd. Thanks for inviting me to discuss this very important issue.
Unger: Well, to set the stage for our discussion, I'd like to start by asking, what does inclusion mean to you and your team at the Permanente Medical Groups?
Dr. Chukwumerije: Yeah. Thank you for the question. Equity, inclusion and diversity, like you know, when we talk about them, people think it's just one thing, right? The acronym EID or DEI, however you want to look at it, or whatever your organization uses to describe, it is really interrelated. But each component is different.
So inclusion, the way I remember that, is that there is diversity and inclusion expert that says that—the name is Verna Myers—really talks about diversity like being invited to the party. But then inclusion is being invited to dance. Because you can be invited to a party and then you are by the sides, right, watching others dance. But are you really included? Are you really invited to dance?
I think it makes a significant difference in terms of that. So inclusion, the way we look at it in the Permanente Medical Group, has to be intentional and proactive. So you have to be intentional with inclusion. Diversity may just happen, but inclusion has to be intentional.
So what do I mean by that? I look at myself today, I'm the executive medical director in Georgia. But about eight years ago, the executive medical director, our medical director in Southern California where I was, I was a member of our leadership team, but I never imagined myself being a medical director myself.
But when she was leaving, she made the effort. She was very proactive and intentional by telling me that, "Hey, Nkem, have you ever thought of applying to become a medical director?" So that's an inclusive act, right? So that's inclusion, being intentional, for example. And her name is Mary Wilson. I never forget that.
So it's really inviting people to participate, despite having diversity on your teams. And I think that is really very important. That's how we look at inclusion, different from just diversity and equity within our medical group.
Another way that we look at inclusion is also being very inclusive in the way we approach health care so that we're not just talking about medical care, we're also talking about medical, social and the mental well-being of a patient. So you're inclusive in your approach to that.
Unger: Now, inclusion plays an important role in your work, obviously, especially at this moment. Earlier this year, you spoke on a panel and you said that prioritizing inclusion can help keep people engaged in health equity efforts. Can you talk a little bit more about that?
Dr. Chukwumerije: Yes. I mean, what I was referring to during that panel discussion is the—when you talk about DEI, especially in the last few years, some people have a negative reaction to it. But when you talk about inclusion, it really speaks to everyone. And everyone tends to kind of—they have had moments where they've felt excluded.
So are you talking about inclusion, especially gender inclusion? Have we been making sure we're including all the gender, different age bands in our decision making, making sure that we're inclusive in everything we do? Some people feel excluded from participating, for example, in leadership within the medical group.
So when you emphasize inclusion, you're more likely to open the minds of everybody to see the benefits of diversity, equity, and inclusion. So that's another way to look at it. And also, like I mentioned to you, being inclusive in your thinking is really very important, even as you're driving health equity, for example.
I talked about total health, which is our approach to health care in Kaiser Permanente, is really ensuring that at time zero we are thinking about both the physical, mental and social well-being of our members. That's how our system is designed. So we're inclusive in that direction.
The other way we look at inclusion is also in designing our systems, right? Are we making sure that as we are designing our health care system, we are thinking about the vulnerable populations that we serve? Because you can't give the same health care to everybody. So you need to make sure that we're taking care of our frail elderly, for example. Designing programs and systems that addresses their need.
Members with socioeconomic gaps, have we designed our system to identify those gaps and make sure that we're filling those gaps? Digital offerings, making sure that everybody has access and is included in that process?
Unger: Can you give me an example of how focusing on inclusion has contributed to your health equity efforts at your organization?
Dr. Chukwumerije: Yes, I think, let's take the instances that I gave and give examples for each and every one of them. I think, for example, if you think about—one that comes to mind is here in Georgia, we have what we call the Cocoon pregnancy model. So the Cocoon pregnancy model—it was published in the New England Journal of Medicine about two years ago. It was developed here in Georgia.
We observed, in Georgia, really, maternal mortality is very high, disproportionately in Georgia, but more so the likelihood of a Black pregnant woman dying is three times more than the white in our population here. So we had an inclusive design process where our people came in to design a program called the Cocoon model, that has layers of safety and support for the moms before, during and after pregnancy.
And the idea is that we are making sure that we are monitoring them for hypertension and diabetes, which could result in preeclampsia and eclampsia, one of the highest causes of the mortality. And so we give every pregnant woman an opportunity to actually have remote patient monitoring with high blood pressure. And we do that and extended the period of monitoring even after pregnancy.
So being inclusive in our thinking as we design our program around the pregnancy care resulted in significant decrease in the disparities in maternal mortality in Georgia. And like I said, we are spreading that across the country now. And I think that's one example. So you have to be thoughtful that you're inclusive in that process and thinking about all the populations that you serve.
The other area is a program where we call the GeriPop program. So these are geriatric—some people would—the frail geriatric population. These are population of our elderly folks who are not necessarily towards the end of life. They don't need hospice or palliative care. But you know that they're frail and elderly, and they may not be able to get out of their home to seek primary care and to get all the care that they need.
So being proactive and designing programs where we actually reach out to those members to do primary care and to make sure that we are connecting them to the social programs and all the medical care that they need is another example of how being inclusive in your thinking and making sure that all programs, all the populations that we have are served.
Unger: Yeah, those are two great examples. And what I'd love is to get your advice on how other organizations should take kind of similar steps as they want to focus more on inclusion after they hear what you're doing.
Dr. Chukwumerije: Yeah, I think all organizations, what they should, again, is really thinking about—that's why I said that equity, inclusion and diversity are related. There is no way that you can have health equity or deliver on health equity without being inclusive in your design and thinking.
Because U.S. has a variety of populations of people, so how do you design your programs to make sure that they are meeting the needs of our members? I think it's a mindset shift. I'll tell you what I mean by that. We used to define some of these population of our membership as being high utilizers. That is, that they require more care than others.
But we shifted our mindset from looking at them as high utilizers to actually looking at them as members with complex needs that we are not meeting. So if we were to meet the needs of our different populations in different ways and be inclusive in that thinking, then we actually decrease their utilization. But more than anything else, you deliver the care that you need to deliver to them.
So it's really leadership, understanding the need to reinforce the idea of inclusion in all that they do.
Unger: How do you keep your care teams engaged with all the equity efforts that you've got going on?
Dr. Chukwumerije: Yeah, I think the way we keep our care teams engaged, there's a few ways to do that. If you think about it, there is this—I think it's Robert Livingston, who is a social psychologist, has his model. And the model that they describe is the one they call the PRESS model—P for problem awareness; R—root cause analysis; Empathy; Strategy; and Sacrifice.
And the idea is that you can't get to the point of empathy and the sacrifice needed by the care teams unless they are aware of the problem we are trying to solve. I think it's really very important that we create a problem awareness and root cause analysis.
So in Kaiser Permanente, we actually have what we call Belong@KP, parts one and two. Part one is actually talking about unconscious bias and how we have to be aware of the need to make sure that we're inclusive. And part two is a root cause analysis that talks about systemic racism and some of the unintentional cost outcomes we see just because of how we've designed health systems over generations.
So if you create the awareness and make sure people understand the root causes, they're more likely to have the empathy and sacrifice needed to go along. The other way we do that in our organization is also, we actually have embedded it in the way we deliver care.
In Kaiser Permanente, I think our differentiation is really the long view of care. So what do I mean by that? So the long view of care is the fact that when a patient comes to see us, for example, they may come for a skin problem, that the dermatologist is not just addressing the acne, why they're there, but they're asking the question, what might the patient need from a medical perspective? Have they had their mammograms?
Did they do their colorectal cancer screening at time zero, at all points of care? And we're also not just doing it for medical. We actually designed our program that we're doing it for non-medical gaps, which is the social determinants of health. So we are actually asking for nutrition, SSI socialization, caregiver support, advanced care planning and additional resources that a member may need.
So our system is designed that at time zero, we are doing the long view of care medical, non-medical. So that kind of reinforces it because we have our templates designed that way. And everybody has the same question at all points of care. So it reinforces the fact that inclusion, diversity and equity and all that total health is very important. And that's the only way you can deliver on value-based care too.
Unger: Very interesting. Do you have something kind of big on the horizon in terms of your set of initiatives?
Dr. Chukwumerije: Yeah. I have something we are thinking about. So if you're in Georgia, where I serve as executive medical director, south of the I-20, and not of the I-20, are really, really, really different health care systems. I don't know whether you've heard about it recently. But two hospitals, we are close south of the I-20.
So the access to health care is more challenged. There's a lot more socioeconomic gaps in the south. And then there's a lot more disease burden on the south. So what do you do about that? So what we are doing is redesigning and rethinking our system to provide the right support.
What we are thinking about thrive hubs in our medical office buildings, to be able to create a hub where we have the right case managers and social workers that will actually support our care teams as they deliver care to these complex populations that we serve in the south side.
So we are beginning to develop that program. And the idea is, again, is thinking being inclusive in our thinking. We cannot continue—we cannot do the exact same thing we are doing in the north when we have different results in the south. So we need to think about it and be inclusive in the way we support our care teams as they deliver care to our members.
Unger: That makes a lot of sense. Dr. Chukwumerije, thank you so much for joining us today. This work is so essential and your perspective and insights on it are really helpful. If you found this discussion valuable, you can support more programming like this by becoming an AMA member at ama-assn.org/join.
That wraps up today's episode. We'll be back soon with another AMA Update. In the meantime, you can subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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