Abt Conversations: Health & Equity - Minnesota

Good health and safe environments are important to everyone. Increasingly, federal, state, and local partners are seeking ways to improve health for all people, no matter where they live, who they are, or how much they earn. In this podcast miniseries, Abt staff sit down with health leaders from Massachusetts, Minnesota, and the Pueblo de San Ildefonso to discuss ideas on health equity, including challenges, innovative approaches, and next steps for their respective programs and communities. In this episode, Abt's Sara Galantowicz talks to Erin Flicker of Minnesota's Department of Human Services.

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Sara Galantowicz: I'm really excited to be joined today by Erin Flicker who is the co-lead for Abt's work in the state of Minnesota on our HCS access contract. Erin is a supervisor within the Minnesota Department of Human Services, which is the agency responsible for the Minnesota Medicaid program. Hi Erin, thanks so much for joining me here today.

Erin Flicker: Yes. Thank you for having me.

Sara: So, I know from our time working together that promoting health equity, especially among historically underserved populations, is a core goal for the Minnesota Medicaid program. What does health equity look like to you? How are you going to know when you're actually making progress in this goal?

Erin: Yeah, that's a great question. And, from my role—I oversee research and evaluation across community supports and continuing care for older adults administrations at the Department of Human Services—and I am seeing efforts to increase culturally specific and culturally informed services and providers across the whole agency. We're making health equity a part of our work across these areas, including services, processes, organizational performances, and outcomes.

One of the projects that I'm working on now is actually a community based participatory research project which is trying to understand disparities in the assessment process for home and community based services across the state. And part of this project is integrating the findings afterwards into our work by developing measures to track disparities in this assessment process over time. And what we've learned throughout this process actually is we don't know exactly what the outcomes are that we're trying to achieve yet because we're trying to do things a little differently this time. Unlike in the past, we're not doing it for the purposes of outcomes per se. We're doing this work to better understand how the people across the state are using services and to better understand what they're identifying their needs and preferences are to inform how we're moving forward. We actually have several initiatives like this happening across the agency, and it's really exciting to see how we are redefining what we've historically considered success and how we are supporting health equity.

Sara: That's really exciting. And, certainly, being able to understand and measure is a key part of the health equity journey. Are there some key strategies that the Department of Human Services is pursuing to promote equity and reduce disparities in its Medicaid programs, outside of the ones that you've already mentioned?

Erin: Yeah. We are working to embed an anti-racist and equity lens across our policies and decisions and behaviors on the whole. I'm trying to think … An example of this would be incorporating an equity analysis into decisions that we're making. We do equity analyses of the policies that are being proposed. We're reviewing existing policies and practices through this same equity analysis to make sure that we are considering all aspects of policies and the impact they may have.

Another example is, like I mentioned, this evaluation I was working on before. We formed a community advisory board as part of this project—and this is a practice that's happening more and more as we're engaging with communities across the state—and this community advisory board was an integral part of the process. We were able to bring our quantitative data to the board to help us better understand and interpret what we thought we were finding. They've also been able to guide next steps in our project.

A third option would be that we are making demographic data more available to policy experts across the state so they can use it not only when they're making really big changes, like legislative proposals, but also in their everyday work. These are showing up as we have a demographics dashboard that's publicly available that people can access across the state. And then we have public performance measures as well so that our partners, counties, tribes, providers, other advocates, they can access this data as well and use it in their work as we're coming together to try to create meaningful policy to support people.

Sara: I'm really intrigued by your demographics dashboard. How do you find use of the dashboard? Is there a lot of uptake with the information that's there?

Erin: You know, I'm finding that once people become aware of it, it is used very regularly. I think that we still have some work to do as far as spreading awareness that the dashboard does exist. And much of that data that we get asked for regularly is available for anyone who has access to the internet to be able to look for and review for the past five years. And so, folks who know about it definitely use it.

Sara: That's great. Yeah. Certainly access to information is a key first step in the whole journey towards equity.

Erin: Yes.

Sara: Speaking of dashboards, we at Abt have had the opportunity to work closely with DHS in the last several years to measure access to Medicaid home and community based services, including access to critical services, developing a dashboard, developing indicators, really trying to bring that information as a tool to the state staff. How do you see this collaboration that we've had over the last several years supporting DHS's equity strategy?

Erin: Yes. And we've really appreciated the dashboard that was designed with Abt. It's interactive and it's really a great way to enable our program staff to see trends over time in a really nuanced way where we can look at differences that are happening across the state as a number of different measures, instead of just looking at one measure, such as utilization. So that's been a fantastic addition to the work that we can offer our program and policy staff.

But I think that you've really done a lot in supporting us to find those quantifiable indicators of access. And once we have those quantifiable indicators, we can uncover more service access disparities and look at the impact that our policy and program changes have, both over time but also by geographic areas, which is something that's really important in our state. There's some significant differences in rural versus urban areas as far as who's being served with different programs and what service needs may be.

Sara: Yeah, that's a good point. Those geographic disparities are an important part of the whole health equity conversation. And we've really enjoyed partnering with you and the advisory panel to think about what are the key subpopulations, what is the important way to filter the data to try to uncover some of these discrepancies, and then use that as a basis for figuring out what are the interventions to achieve equity.

Erin: Right.

Sara: Just last question. We know that the journey to health equity is a long one. It's a process. What have been some of the challenges that you've encountered in this work or some of the successes and sort of lessons learned that you're carrying forward as you're looking across equity issues across the state?

Erin: First, I just wanted to say that I am really impressed with how much progress we've actually made on having conversations around equity. And I want to recognize that conversations aren't necessarily an outcome of equity, but it really does demonstrate how some of these conversations and some of these equity practices and equity analyses have become a norm. And there's more of a willingness to lean into some of that discomfort for change. It's been really interesting to see the number of state employees that come to meetings prepared to discuss their interpretation of the equity analysis that we are doing. Yeah, it's been really fantastic.

And, at the same time, I can say that we still have a ways to go with how we're doing the work. One example that comes to mind is a challenge of really having ... In my role specifically, I run into this quite a bit. It's really having the right data to be able to understand the nuances of the different communities across the state. We capture data on people who identify as African American or Black, for example. But we can't actually use that data to discuss what is affecting Somali refugees versus African descendants of slavery. And we know that the cultures and the needs of those groups are going to be significantly different from one another.

We are working right now on moving towards updating our demographic questions that we have for all of our state systems to reflect some of this more nuanced capturing of people's identities for race, ethnicity, and gender. And this is exciting work. We're partnering with community members. We've connected it to the community advisory board that I referenced earlier as well. So we're able to bring in communities across the state to work collaboratively to try to update our systems as much as we can so we can better have an understanding of what it is specifically—who it is, rather, specifically, that we're working with and what it is that they may be needing more from us.

Sara: That's really interesting. I know early on in our work with you, we were looking at results by race and trying to figure out what were the information sources that we could use to disaggregate the immigrant population from the long-standing African American population in Minnesota. And it is a challenge to try and separate those data sources. So very interesting and exciting to hear that you're looking at collecting that information to allow you to have that more granular profile. So very cool, some very cool work that you do in Minnesota.

Erin: Yes. I love being a part of it. And I've very much enjoyed partnering with you in some of our processes as we're moving towards this.

Sara: As have we. Thank you so much for taking the time to talk with me today. I really appreciate it. And looking forward to our continued partnership.