The self-described characteristics of the 20 community leaders who participated in the listening sessions are in Table 2. The identified three themes about quality primary healthcare clinics and representative quotes are in Table 3.
Theme #1: Quality Clinics Utilize Structures and Processes that Support Healthcare Equity
Recognize and address historical trauma, structural racism, and social determinants of health (SDOH)
Many community leaders discussed how the social injustices resulting from historical trauma, institutional racism, and structural inequities have negatively impacted the health of their communities. These mechanisms have contributed to communities’ high disease burdens, difficulties accessing healthcare, and a lack of trust in the healthcare system. Participants indicated that these complex and interconnected mechanisms cause (physiological and psychological?) stress from repeated daily inequities, which contribute to chronic diseases.
Recognizing and addressing historical trauma, structural racism, and SDOH in these communities is an important contributor to healing for patients. Primary healthcare clinics need to improve their ability to identify, understand, and address social factors that influence health, as well as adjust clinics’ healthcare processes so they do not perpetuate inequities. Providers should be trained in how to appropriately inquire about historical trauma, structural racism, and SDOH as this helps alleviate patients’ fears. They should consider these issues in both diagnosis and in treatment, making decisions in collaboration with patients. Clinics should have structures that include “real” representation from the clinic disparities. lIn addition, clinics should authentically engage and partner with community organizations to address the societal issues that negatively influence health.
Have real representation by patients and community members
Community members of the patient populations that are served at each clinic need to be represented throughout the clinic including staff, clinicians, and clinic managers, to executive leaders and board members. “Real” representation means they have authority and play active roles in the decision-making process, in contrast to “token” representation when people do not have meaningful input or decision-making power. The current power structure means that healthcare systems tell communities "you should be this", when communities instead should more actively define their health and healthcare by being immersed in the organizational structure. Clinics need to intentionally cultivate relationships with trusted community members and leaders to best develop effective partnerships, which can contribute to improved patient trust, communication, connection, and healing relationships.
Report on health disparity data, goals, and efforts
Clinics should report on their health disparity efforts by creating an “Equity Dashboard” that highlights existing health disparities and illustrates directions for progress and improvement. Collecting and displaying data can lead to improved understanding of current practices, goal setting, and accountability. The dashboard could include: a) clinic policy leadership level data; b) clinic process data; c) clinic outcome data; and d) patients’ negative experiences with clinic processes and clinic relationships, such as being treated with disrespect/discrimination or stereotyping. An “Equity Dashboard” could help clinics explore and display how SDOH affect families and communities, how structural racism impacts community health, and how institutions respond to concerns of inequities and discrimination from patients.
In discussing whether or not clinics should be required to collect SDOH information, opinions were mixed. Participants saw potential value in providers being able to better understand patients in the context of their lives and refer patients to appropriate community programs and agencies. Potential harms included patients’ confidentiality and desire to keep this information private, increased vulnerability, and potential for discrimination. Community leaders thought perhaps it would be best for communities to be able to collect and manage their own data, being able to set their own priorities. Ultimately, they thought it was best for clinicians to respectfully ask patients about their social situations and clinics could collect the data anonymously.
Improve access to care through solutions to barriers and integrated services
Improving patients’ access to care includes aspects outside of the clinic (insurance, transportation, location, etc.) and inside the clinic (hours, appointments, interpreters, etc.). Increasing the prevalence of integrated services, like “one-stop shops” for healthcare that includes physical and mental health, will improve patient and community health through ease of access. Traditionally, healthcare clinics have focused on physical health, and have relegated mental health to special mental health services. Patients, families, and communities could benefit from the expansion of mental health services to be diffused throughout the primary healthcare system. Clinics should also partner with community spiritual, social, and mental health healers.
Although not directly responsible for the financial burden of care, clinics could support long- and short-term solutions for the high cost of care. Long-term solutions should include universal healthcare coverage, while short-term solutions could include: clinic-based discount programs; providers prescribing medications that patients can afford or are covered by insurance; and pharmacists connect with pharmaceutical company assistance programs.
Support healthcare system navigation
In order to best navigate the clinic and healthcare system, patients need to understand how the system works. Transparent clinic processes will help patients understand how the system can help meet their needs (i.e., understanding diagnoses, treatment plans, test results, medical/community referrals, and follow-up care). Effective communication then must make these transparent processes easy to understand by considering patients’ language, health literacy, numeracy, and technology skills.
Create welcoming, private, and safe clinic environments
Healing environments reduce stressors associated with the effects of societal discrimination and disrespect. Clinic spaces could include space and activities for children, artwork from local artists, healing gardens, and quiet spaces for reflection and prayer. A welcoming environment requires clinics to have a high standard of professionalism that reflects the needs of the communities they serve. Furthermore, providing confidential care in a private environment is respectful of patients and leads to a trusting relationship between patients and clinic staff.
Theme #2: Quality Clinics Offer Effective Relationships, Education, and Health Promotion
Support effective and longitudinal clinician-patient relationships
Patients want long-term personal relationships with their primary care clinicians. This relationship should include respect for patients as individuals, acknowledgement and not dismissal of patient concerns, and respect for patients’ life choices. Patients desire support and advice for all of their healthcare-related needs, including acute and chronic conditions, preventative care, healthy lifestyle, and overall wellness. Clinics should provide adequate resources and time to help patients develop effective and therapeutic relationships with providers. Clinicians need adequate time to establish personal relationships, provide culturally-responsive care, and identify and respond to relevant SDOH factors. Trained medical interpreters are also a necessity to best serve non-English speaking and low English proficiency patients.
Provide training for staff to improve cultural-responsiveness and be attuned to unconscious bias
In order to help patients feel valued and respected, all clinic staff should be required to complete cultural-responsiveness training. Such training aims to mitigate implicit biases, stereotyping, and discrimination. Providers and clinic staff who understand a group’s history, culture, and healthcare practices (i.e., herbal medicine, massage, or prayer) can provide more patient-centered care and help avoid patients feeling vulnerable, misunderstood and stereotyped. Staff need to provide excellent customer service without making assumptions, reinforcing stereotypes, or passing judgment based on how people look, dress, or speak. Overall, culturally-responsive care improves patient trust, shared decision-making, patient engagement, and follow-through with healthcare goals and plans.
Provide culturally-relevant patient education
Traditionally, clinics have focused on doctor-dominated disease diagnosis and treatment with patients being dependent on clinicians. The shift towards focusing on prevention, health promotion, and patient empowerment for healthy goals and independence for chronic disease-self-management needs to continue. Effective patient education is holistic and tailored to individuals in the context of their family and community. It must remain consistent with patients’ preferred language, literacy, and learning styles, while also considering peoples’ cultural values of health and healing, and respecting patient’s intersectional identities.
Integrate family and community-based strategies for health promotion
Individually-focused care can fracture the family and community structures, isolating individuals from their support network. Family-focused health promotion and education can support healthy lifestyles for the whole family, while using patients’ support systems to empower them. Culturally-responsive healthcare for communities that value a collaborative versus individualistic view of health may mean including family and friends during patient visits.
Theme #3: Funding Based on Current Quality Measures Perpetuates Health Inequities
Community leaders generally disparaged the reality of the current system, where privileged patients and communities have higher quality scores than impoverished clinic populations. They recognized that if the clinics serving privileged communities receive increased reimbursement while clinics serving impoverished communities receive less money, the social injustice of our healthcare system and its disparities will continue.