The headline might read like alphabet soup or a text message found in a teenager’s phone but the acronyms are actually an integral part of Alameda Health System’s (AHS) plan to address population health.

Collecting race, ethnicity, and language (REAL), sexual orientation and gender identity (SOGI) and housing data will help AHS meet the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program requirement to capture granular population data, pinpoint disparities within specific populations and develop plans to reduce these disparities. Reimbursement will be based on how well the system addresses targeted disparities.

Neha Gupta, M.D.

“At AHS, we believe that our patients’ health is more than a collection of diseases or lab values. Early in 2018, after a series of robust trainings for staff and providers, all primary care clinics began asking patients about SOGI in addition to the existing questions about REAL and housing,” said Neha Gupta, M.D., medical director for the AHS PRIME team.

Now that that data collection and disparity identification is underway, AHS will be required to demonstrate better health outcomes in these communities annually. The data collected will be instrumental in helping AHS design programs to help give patients better quality of care.

To support collection of the information, AHS will be rolling out the “We Ask Because We Care” initiative with materials to help patients understand why certain questions are being asked.

“We hope to create an inclusive environment for all of our patients regardless of how they look, where they come from, how they live, and who they love,” said Gupta. “As part of the initiative, brochures will be available in all primary care clinic waiting rooms, and signs posted at all sites.”

Social determinants of health like where people are born, grow, live and work, play a huge role in health inequities and health disparities. For example, the Alameda County Public Health Department reports that Pacific Islanders life expectancy is 77.6 years, compared to 83.8 years for Latinos.

Health disparities are not only found in communities of color, they are also prevalent in communities of people who are homeless or have different sexual orientations. According to the Joint Commission, Lesbian, Gay, Transgender and Queer (LGBTQ) individuals experience disparities not only in certain physical and mental health concerns, but also in care due to a variety of factors including experiences of stigma and insensitivity to their unique needs.

Additionally, the National Health Care for the Homeless Council state that people experiencing homelessness have disproportionately high rates of acute, chronic disease and behavioral health conditions.

AHS has always strived to offer culturally competent care to our diverse patients in a variety of ways, including interpretation and translation services in 26 languages. SOGI, REAL and housing data will help extend that mission by providing more targeted care and interventions for specific populations in Alameda County, with the goal of improving health outcomes for all.