Black ER patients are less likely to receive follow-up care, and this project is examining why

A new Michigan project is engaging community-based organizations to gather information on, and develop solutions to, disparities in ER follow-up care.
This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Follow-up care is often crucial for patients after an emergency room visit. But Black patients in Michigan are much less likely to return for follow-up care than white patients – in some cases by 20% to 30%.

The reasons for – and solutions to – this gap are the subject of a new project led by Dr. Sabrina Ford, an associate professor in the Michigan State University College of Medicine Institute for Health Policy. Ford's work focuses on public health programming and reducing health disparities for vulnerable populations. Her current project, funded by the Michigan Health Endowment Fund, focuses evaluation and research on documented disparities in follow-up care among Michigan's Black patients who have been admitted to a hospital emergency department. 

A 2021 review by the Michigan Public Health Institute (MPHI) found significant disparities between Black and white patients for follow-up care after an ER visit, with the highest disparities occurring after visits for alcohol and other drug use dependence. Ford's project is aiming to remedy some of these disparities by engaging community-based organizations (CBOs) who work directly with Black communities. Ford's project targets Oakland, Wayne, Kalamazoo, and Saginaw counties, which showed the highest disparities – those in the 20% to 30% range – in the MPHI report. Ford has identified CBOs in those counties who will gather information from people who didn't get the ER follow-up care they needed.

"The community-based organizations are collecting their own data. They are at the ground level, the grassroots level. They know their community best," Ford says. "They've done focus groups. They have done one-on-one interviews with stakeholders, clients, or patients. Some of them are actually collecting data from around the state in terms of what are the barriers and facilitators to getting treatment. We'll be helping them culminate and then analyze the data."

By convening stakeholders to determine how to address the disparities, Ford's helping to connect hospitals, community mental health organizations, and other CBOs in creating a bottom-up approach that includes gathering feedback from the affected populations and involving them directly in solving identified issues. The CBOs involved are currently gathering that information with hopes of developing solutions by August for implementation in 2023.

"What we're finding from what the people in the community say, is that a lot of it is stigma. African-Americans have either been discouraged from using the system, not intentionally or directly. But the experience is so uncomfortable that they tend not to go back," Ford says. "And [they've found that] people who are medically underserved are also underserved with child care, transportation, and all the other things that the neighborhoods where the CBOs work typically don't have ready access to."

Wayne County CBOs collaborate to reduce disparities

Two of the Wayne County CBOs that Ford has engaged in the project, Changing Lives and Staying Sober (CLASS) and Self-Help Addiction Rehabilitation, Inc. (SHAR), address substance use disorder treatment.

"Here we have the double stigma of being African-American and the stigma of also having a substance use problem," Ford says.

SHAR has provided behavioral health care services to the Greater Detroit area since 1969, evolving from a small therapeutic community based at a local parish to a multi-million-dollar human service agency serving around 6,000 people a year at its various service centers.  CLASS is a provider of prevention, intervention, and residential and outpatient substance use disorder treatment services. In partnership with Ford, the two CBOs have launched a joint Racial Disparity Project to examine why Black patients are so much less likely to return for follow-up care after an ER visit.

The hope is to uncover the spectrum of barriers Black patients experience to accessing behavioral health follow-up care in their community. The CBOs are reaching out to local community members — Black residents, others with lived experiences, health plans, substance use and mental health agencies, nonprofits, hospitals, and other community groups — for the answers to that overarching question. As an incentive, community members completing a survey receive a $10 gift card.

"We are working together to provide innovative solutions to what we recognize is an issue in our community in terms of access and barriers to not just follow-up care, but care in general," says Dr. Karla Mitchell, executive director of CLASS. "We're just now analyzing all of the data collection that we spent the first 90 days doing. We did a series of focus groups, interviews, and surveys of the behavioral health care consumers, their family members, and clinicians to ask a series of pointed questions about why people are not returning to the doctor for follow-up care."

While it's too early to release official findings, Mitchell shares that one area of concern that has come to the forefront is that CLASS clients rarely seek medical care outside of a crisis situation. The reasons for this are complex, but lack of sufficient income to take time off work, secure transportation, or cover child care costs plays a crucial role.

"It's a priority thing. If I leave my kids at home by themselves, I can lose them. If I don't have a car, that impedes my ability to follow through," Mitchell says. "I hope we're able to define a solution that addresses all those barriers at the same time and creates stronger connections with the institutions, the community-based organizations, and the consumers."

And with health clinics being understaffed and providers overworked, relationships that encourage follow-up are hard to build.
Dwight Vaughter.
"There are providers who have implicit biases, who think, 'Well, you should do better for yourself.' They're insensitive to those barriers," says Dwight Vaughter, CEO of SHAR. "And then there are others who just simply do not have that passion, care, and concern, who are willing to go the extra mile to make sure people get the services that they need. I think it's a two-sided coin."

Making a difference in Oakland County

In neighboring Oakland County, Ford is collaborating with Oakland Family Services to find ways to improve follow-up care rates for people of color there. Oakland Family Services provides foster care and adoption programs, parenting programs, early childhood education and care, and counseling services for mental health challenges such as depression, anxiety, and addiction.

"My sense is that there are multiple issues. Stigma is one that most communities experience in terms of reluctance to receive mental health or substance use treatment. People still see it as something shameful, which it shouldn't be. These are diseases," says Natalie Marchione, vice president of quality and planning for Oakland Family Services. "Lack of transportation is often an issue, which we've seen for years in terms of people not attending treatment. Since the ability to do telehealth, people come more often to treatment."
Natalie Marchione.
Marchione looks forward to identifying the barriers to follow-up care impacting residents in Oakland County communities. One strategy she envisions would be to provide services in other familiar neighborhood locations outside of the clinic.

"When we're providing in-person services, it has to be at our three locations," she says. "Most of the insurance companies require services to be provided at the location. Looking at doing treatment services at other locations where somebody might feel more comfortable, like a local church or community center, they might not feel as stigmatized as coming to an office where people receive mental health and substance abuse treatment."

As Oakland Family Services and all the CBOs working on this project identify issues and solutions, their shared experience will provide Ford data and ideas for decreasing disparities and empowering Michigan's Black residents to get the follow-up health care they need.

"This is a huge issue that we need to address," Marchione says. "The more I'm involved in the project, the more I hear about the kinds of disparities that Black people and people of color face. These disparities are astounding and sad and tragic and have to change. I'm happy to be a part of a project where we might be able to figure out how to make a difference."

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

All photos courtesy of the sources.