Level: Who the activity will target?  While all disparities reduction projects are meant to impact patient outcomes, the patient isn’t always the primary target of the activity.  For example, provider cultural competency training is designed to improve patient outcomes. It is accomplished by facilitating change at the level of providers.  There are six potential levels of influence.

Patients
Providers
Microsystem (immediate care team)
Organization
Community
Policy

Strategy: What the activity will do?

Delivering education and training
Engaging the community
Restructuring the care team
Providing financial incentives
Providing reminders and feedback
Enhancing language and literacy services
Increasing access to testing and screening
Providing psychological support

Mode: How the activity will be delivered? Mode is the channel used to deliver the activity to its intended target. Note that each strategy must have its own mode. Some activities will rely heavily on technology-driven modes of delivery while others may use more traditional methods.

         
In-person or face-to-face meetings
Telecommunication
Internet
Information technology
Print materials
Multimedia

Note that a single disparity activity can target multiple LEVELS of influence; each with an accompanying STRATEGY and MODE. Also note that single STRATEGY may require more than one MODE.

An example of how the building blocks can help you think about your activity design is the Telephone-Based Depression Care Management, designed and implemented by the Neighborhood Health Plan of Rhode Island (NHPRI). 

NHPRI cares deeply about the quality of care their patients receive. The team thought carefully about their equity activity and took the necessary time to professionally design and implement it. NHPRI staff members were highly motivated to improve care and reduce disparities and they expended significant resources to restructure their care team.  Before their evaluation project was funded by Finding Answers, a team of national experts reviewed their proposed activity and thought it showed significant promise.

How did they design their activity?

NHPRI was aware that Latino patients with depression receive less treatment and have poorer treatment outcomes compared to non-Latino White patients. They took several steps to gather information that informed the design of their equity activity, including:

• Conducting a literature review of depression interventions for Latinos.
• Consulting with their staff members and organizational partners, emphasizing feedback from individuals who identified as Hispanic or Latino and individuals with extensive experience working with the Latino patient population.
• Investigating prior effective NHPRI telephone-based interventions for other health conditions.

Based on the information gathered, NHPRI felt that patients needed more intensive, one-on-one care outside of the clinic setting to improve the quality of care and patient follow-up. So, patients were the primary LEVEL of intervention. NHPRI also concluded that patients would benefit from culturally competent education about depression, supportive contacts and reminders for appointments and self-care. These became their primary STRATEGIES.

NHPRI also felt that it was important to culturally tailor their activity and did so by hiring bilingual and Latino depression care managers to work directly with the patients. These new members of the care team would also have the time and skills to work effectively with patients. So, another STRATEGY of their activity became restructuring the care team at the LEVEL of the mircrosystem.

Finally, staff and leadership at NHPRI assumed that using the telephone as the main source of communication between care managers and patients would be convenient, less labor intensive and less expensive than face-to-face meetings. As a result, they chose telecommunication as the primary MODE of delivering their intervention.

The NHPRI activity looks like this when using the Tools building blocks:

*Sometimes, a program won't need a MODE of delivery. For example, NHPRI restructured their care team by adding bilingual and Latino depression care managers. The care managers used the MODES of Telecommunication and Print to deliver the patient-LEVEL STRATEGIES, but 'restructuring the care team' meant making changes to the system, which isn't associated with any particular MODE of delivery.

Did their equity activity succeed?

Unfortunately, NHPRI found that their Latino patients showed little interest in their equity activity. Very few of them chose to participate. The team tried many different methods to increase the number of participating patients, but nothing seemed to work.

What did patients and community leaders have to say?

After holding patient focus groups and consulting with leaders from community based organizations, NHPRI learned it was because the intervention used-up patients’ valuable cell phone minutes that they could not spare. In addition, patients were uncomfortable talking with a stranger on the phone about depression and said they may have been more willing to participate if they had been directly invited by their primary care provider.

What happened?

While many aspects of the NHPRI equity activity were strong and quite logical, they made a key error. Instead of working directly with their patients as part of their root cause analysis they felt that their Latino staff and providers would be able to serve as a sufficient proxy when designing a culturally competent intervention. NHPRI found that patients had different ideas about which STRATEGIES and MODES of delivery would work for them. NHPRI’s experience is not uncommon; any organization will decrease its chances of success if they neglect working directly with their patient population while conducting the root cause analysis and designing their equity activity.

It is important that you avoid a critical, but common, error.When designing equity activities, many organizations forget to apply what they learned in Step 3, Diagnosing the Disparity when putting together their equity activity building blocks; the root causes of the disparity and the most feasible and important causes to address.There are three things that you can do to avoid this error.

 1.      Review the information you learned in Step 3 before making your final LEVEL, STRATEGY and MODE choices.

Seeing the many possibilities and examples of others’ activities might tempt you to use one that “seems” or “feels” like the best choice.It is critical that each LEVEL, STRATEGY and MODE choice relates directly back to the information you gained from your Root Cause Analysis, patients and other stakeholders.

 2.      Present your proposed equity activity to leadership, staff and, most importantly, your patients before implementation.

They can let you know from their own unique perspectives if the equity activity is likely to succeed.Having to redesign your idea at this stage can be frustrating, but it is a much less expensive error than finding out post-implementation that your activity does not work. Another way to avoid expensive implementation errors is to pilot test parts of the intervention before fully rolling-out the activity using PDSA cycles or testing out the entire intervention with just a few people initially.

 3.      Proceed with caution if you choose to expand or repurpose a STRATEGY for your equity activity that already exists at your organization.

It's important to wisely use existing resources. Incorporating equity efforts into all quality improvement activities can be very helpful. Likewise, repurposing or adapting an existing STRATEGY as part, or all, of your equity activity can be one way to foster a successful implementation.  However, be sure that the STRATEGY ties directly back to the root causes of your disparity and addresses the most feasible and important causes to address it (as explored in Step 3, Diagnosing the Disparity).