This blog post is part of our quarterly series highlighting the work of Healthy People 2030 Champion organizations. Healthy People 2030 Champions are organizations recognized for their work to improve the health and well-being of people in their communities and to help achieve Healthy People 2030’s goals.
Novant Health is an integrated network of physician clinics, outpatient centers, and hospitals that deliver health care to communities in North Carolina. With nearly 1,900 physicians and over 36,000 team members, the Novant Health network serves patients at more than 800 locations — including 16 medical centers and hundreds of outpatient facilities and physician clinics.
The organization puts working toward health equity, eliminating health disparities, and addressing social determinants of health — priorities that align with the Healthy People 2030 framework — at the forefront of its work. According to Dr. David Henao, Senior Strategy Execution Manager, Novant Health uses Healthy People 2030 as a benchmark to measure itself against national and population-level data. “At Novant Health, our goal is to be a national leader in health equity and to leverage best practices and tools to provide remarkable care,” says Dr. Henao.
Creating Strategy and Identifying Patient Needs: Best Practice Alerts
Novant Health uses Healthy People 2030 objectives and Leading Health Indicators (LHIs) to identify areas for improvement within its system. For example, it used Healthy People 2030 to evaluate its “best practice alerts” — a system of automated “triggers” that prompt providers to conduct certain assessments and recommend services to help patients stay healthy. Best practice alerts can be embedded into the electronic health record (EHR) system and tailored to a patient’s age, gender, medical history, and current health conditions.
After reviewing the alerts, Novant Health determined that about 50 percent of them map to Healthy People 2030 objectives. For example, the food insecurity best practice alert puts LHI NWS-01: Reduce household food insecurity and hunger into practice. It prompts providers to assess a patient’s food insecurity status by asking them whether the following statements are never, sometimes, or often true:
- Within the past 12 months, you worried that your food would run out before you got money to buy more
- Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more
In 2022, Novant Health screened over 1 million patients because of this alert and identified more than 46,000 patients who had experienced food insecurity in the past year. About 450 patients a month answered “often true” to both questions, which prompted an additional alert about asking if the patient had enough food for the day.
These best practice alerts create an opportunity for providers to connect people experiencing food insecurity to community or emergency resources. “To truly impact the health of the communities we serve, we must assess and address the unique social needs of our patients. Addressing social needs is at the center of health, quality, and patient experience,” says Kimberly Dull, Novant Health’s Director of Social Determinants of Health and Community Health Performance.
Health Equity in Action: Lowering Heart Failure Readmission Rates
Healthy People 2030 objectives have helped Novant Health set ambitious goals of its own and advance health equity. For example, objective HDS-09: Reduce heart failure hospitalizations in adults prompted Novant Health to examine heart failure readmission rates, 30-day returns to the emergency department, and mortality in patients with heart failure. This helped the health system identify a disparity: While the baseline heart failure readmission rate for all patients was 17.5 percent, the rate for Black patients was 19.4 percent — well above the 16.5 percent rate for White patients.
Novant Health set a goal of closing the gap between the 2 groups and lowering the readmission rate for all patients to 16.3 percent by the end of 2023. To achieve this, the health system:
- Increased the number of follow-up visits by adding cardiologists at clinics in the areas with the highest readmission rates
- Standardized the heart failure clinical care pathway, which included increasing the percentage of patients discharged with certain medicines and having their weight recorded daily
- Improved transitional care management by offering house calls to patients who needed a higher level of care
These strategies yielded impressive results: By May 2023, Novant Health had surpassed all its goals. The readmission rate for all patients had fallen to 15.2 percent — and with the readmission rate for Black patients falling from 19.4 to 15 percent (compared to 15.3 percent for White patients), Novant Health also succeeded in closing the gap between the 2 groups. In addition, although emergency department visits remained higher for Black patients than for White patients, the difference was not statistically significant.
Focusing on Underserved Populations: Increasing Breast Cancer Screening Rates
Using Healthy People objectives to improve care is nothing new for Novant Health. As the health system’s Women’s and Children’s Institute turns its focus to Healthy People 2030 objective C-05: Increase the proportion of females who get screened for breast cancer, it’s building on previous success with the related objective from Healthy People 2020.
From 2019 to 2021, Novant Health focused on increasing the rate of breast cancer screenings for all adult patients who met screening guidelines — including transgender men. In particular, the health system wanted to increase the screening rates for Asian and Hispanic patients since they had lower rates (66 and 68 percent, respectively) than either Black or White patients (75 and 74 percent, respectively). At the end of the 3-year period, Novant Health had successfully raised breast cancer screening rates to 75 percent among both Asian and Hispanic patients, an increase of almost 12 percent. It attributes its success to these strategies:
- Speaking to patients in the language they’re most comfortable in — Novant Health hired interpreters to discuss screening options with patients
- Creating media messages and patient resources in more than 10 languages
- Hosting focus groups with patients from prioritized demographics
- Providing appointment reminders in Spanish and several Asian languages
A key takeaway for Novant Health is that working to eliminate disparities can benefit all patients. Dr. Henao puts it this way: “When we work on improving things for a particular demographic group, everyone benefits.”
Lessons Learned
Dr. Henao highlights the following strategies for successfully implementing the Healthy People framework and driving change for people in the health system.
Create advisory groups and name champions.
Identify people within the organization who have a strong interest in doing work in areas of specific need. Early on, Novant Health established a Healthy People 2030 advisory group for each of its institutes and named Dr. Henao as a “Healthy People 2030 champion.” He, along with other members of the Office of Health Equity team, leads efforts to implement the Healthy People 2030 framework across the health system.
Create an implementation blueprint.
Novant Health takes a phased approach to implementing Healthy People 2030. Every 2 years, the organization reviews goals with its institutes and corporate leaders and defines specific actions — like creating partnerships, identifying best practices by leveraging Healthy People 2030, defining health equity for the organization, and recognizing health disparities in clinical outcomes.
Establish 1 quantifiable goal and use data to monitor progress.
Since Novant Health has an aspirational goal to address health disparities across every institute, the Office of Health Equity asked each institute’s leaders to start with 1 measurable goal to work toward. By creating and monitoring dashboard tools linked to specific objectives, Novant Health can track its progress toward the original goals and add new goals with every 2-year strategic planning cycle.
Focus efforts on specific groups.
This approach involves using strategies tailored to meet the needs of historically underserved groups in order to reduce or eliminate health disparities. Novant Health’s successes in addressing gaps in heart failure readmission and breast cancer screening rates demonstrate how effective this approach can be.
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