Health Equity & Social
Determinants of Health
ASPIRE 2023 Collaborative-Wide Meeting
Carol Gray, MPH (she/her)
Program Manager
Matthias Kirch, MS (he/him)
Health Informatics Specialist
Agenda
1. Defining Terms: Shared Language
2. Who is MSHIELD?
3. Addressing Social Needs: Community-Clinical Partnerships
4. Building a Culture of Equity
5. SDOH Data & Measuring Health Equity in Anesthesiology
6. Discussion
Our Team
Sheryl Kelly, PhD, LP
Equity Advisor
Renu Tipirneni, MD, MSc
Co-Director
Primary Care and Internal Medicine
Lindsey Herrel, MD, MPH
Associate Director
Data Strategy & Quality
Melissa Creary, PhD, MPH
Associate Director
Anti-Racism & Equity Initiatives
Matthias Kirch, MS
Health Informatics Specialist
Dilhara Muthukuda, MPH
Community-Clinical
Partnerships Manager
Jordan Greene, MPH
Engagement Specialist
Carol Gray, MPH
Program Manager
SDOH are the conditions in which we
live, grow, work, and play
Neither present nor absent
Neither positive nor negative
Vocabulary matters to guide
interventions
Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion. Retrieved 6/5/23, from
https://health.gov/healthypeople/objectives-and-data/social-determinants-health
Food
Insecurity
Housing
Instability
Lack of
Transportation
Access to
food
Living
situation
Access to
transportation
Social determinants of health v. social
health needs
Social Determinants
of Health
Social Health Needs
To achieve the best outcomes for all patients,
we must address the key drivers of health
80% of our health
is determined by
non-clinical factors
Pursuing health equity means striving for the highest possible
standard of health for all people and giving special attention to
the needs of those at greatest risk of poor health, based on social
conditions.
Paula Braveman, MD, MPH
Health Equity is the Future of
Quality Improvement.
MSHIELD is here to help CQIs
MSHIELD’s mission is to empower CQIs to lead the future of
quality improvement which achieves whole health for all
people by integrating social care and clinical care, using data to
drive health equity, and fostering a culture of anti-racism.
Our vision is data-driven, community-partnered, equity-
centered quality improvement.
Data Strategy &
Quality
Supporting CQIs to use
their data to identify health
inequities and develop
equity-focused quality
improvement goals.
Community-Clinical
Partnerships
Collaborating with
community and clinical
partners to close the gap
between healthcare and
social service systems
across the state.
Culture of Equity
Empowering CQIs as they
root themselves in valuing,
promoting, and
demonstrating equity and
anti-racism in quality
improvement.
MSHIELD supports CQIs and their participating providers to identify
health inequities, address social health needs, and achieve equitable
health outcomes for all patients:
Our Partners
To address patients’ social health needs, MSHIELD works with transformative community hubs
across Michigan:
To learn more about our partners, visit:
www.michiganshield
.org/partners
• Community hubs are regional
networks of community-based
organizations that provide care
coordination services and connect
patients to community resources
• Hubs work at the person,
provider, and systems levels to
ensure that community systems
align to meet residents’ needs
Community-Clinical Partnerships
Health Equity Champions
Goal: to grow each CQI’s knowledge of health equity and
anti-racism
Identify opportunities to incorporate a health equity and anti-
racist approach in the work of each CQI
Commit to 5 hours/month of critical reflection, action labs,
and self-guided tasks
Every CQI has a Health Equity Champion!
Culture of Equity
Measuring Health Equity
• Collecting Key Demographic Data:
Best practices for collecting race,
ethnicity, language, sexual orientation,
gender identity, and disability data
• “Measuring Health Equity
Roadshow” presentation continues
to make the rounds
• Data Consultations with
Matthias Kirch
Data Strategy & Quality
A Shifting Landscape
National Health Equity Quality Measures
• The National Committee on Quality Assurance
(NCQA) regularly reviews and updates
Healthcare Effectiveness Data and Information
Set (HEDIS) measures used by health plans,
hospitals and practices to measure health care
quality
• In 2023, NCQA introduced new HEDIS
measures focused on health equity
Data Strategy & Quality
• New measures on Data Equity:
• Race/Ethnicity stratification for existing measures
• Inclusivity of gender identity to capture sexual
and gender minority members in value sets, such
as those focused on pregnancy
• New measures on Social Needs Screening:
• Capture screening and intervention on unmet
food, housing, and transportation needs
Data Strategy & Quality
A Shifting Landscape
National Health Equity Quality Measures
What is the role of
the anesthesiologist
in health equity?
Moving from observations
to improvements
• Have you observed any patient-specific factors
that affect clinical outcomes? What resources
could help improve outcomes for those
patients?
• Have you observed any issues of equity in your
care of patients?
• Is there information about patients that could
help you provide better care? Is that
information available? Missing?
