2. Integrate social work & nurse care managers into rheumatology practice.
Transportation issues, insurance barriers and complex social situations require a team approach and cannot be addressed by the rheumatologist in isolation. If integrated social work or care management is not possible in the rheumatology clinic, then engaging the patient’s primary care provider or social work team can provide needed support to address barriers.
3. Create outreach rheumatology clinics.
Although barriers to providing care in outreach clinics exist in terms of rheumatologist time and travel costs, these clinics can be an additional tool to provide in-person visits for patients with significant travel burden. Rheumatologists must be compensated adequately for their time and travel costs.
4. Work closely with local clinics to coordinate care.
This approach can be particularly helpful for a patient with internet access barriers. If a patient has transportation to a local clinic, nursing staff can frequently oversee a telemedicine visit and assist with obtaining relevant clinical information. Community health workers, who have been integrated into care for AI/AN communities since the 1960s, can serve as an additional resource for reaching patients.15 Care coordination also includes aggressively managing environmental factors and comorbidities, including tobacco use and obesity, which are associated with an increased incidence of rheumatic conditions, such as RA.16
5. Advocate for reductions in drug pricing.
Drugs used to treat rheumatic conditions, particularly biologics, have significant costs, which has the potential to exacerbate disparity in management and outcomes in rheumatologic disease. Rheumatologists should advocate with legislators, industry and payers to reduce the inequities that arise from the high cost of drugs.
In Sum
Although we have many tools to address healthcare disparities, ongoing research is needed to address additional barriers and gaps in rheumatologic care.
For our patient, we may need to work with social workers to ensure transportation to at least annual or twice yearly visits and augment that with telemedicine visits every three months utilizing her cell phone and electronic medical record (EMR) integrated videoconferencing. We may additionally coordinate with her local providers and provide them with education on disease flares, as well as drug adverse effect(s) and administration considerations. Her treatment will be optimized by initiating combination disease-modifying anti-rheumatic drugs, as well as providing adequate ancillary care and education.
With this type of customized, team-based approach, we hope to better serve our rural and minority patients with effective and ethical care.
