By Melanie A Prince, MSS, MSN, BSN, RN, NE-BC, CCM, FAAN, FCM and Michael Garrett, MS, CCM

Black History Month brings cultural celebrations, recognitions of “firsts” in African-American achievements, and acknowledgments of the African American contribution to history and America’s legacy. As healthcare professionals, it is inspirational to reflect on African American scientists, physicians, nurses, social workers, and other clinicians who have and are making significant impacts in healthcare. We remember Charles Drew, “the Father of the Blood Bank,” who pioneered blood storage and transfusion medicine from his work in World War II. Moreover, we celebrate Dr. Daniel Hale Williams, who performed one of the earliest successful open-heart surgeries in 1893!

Contributing to medicine and science today are living legends such as Dr. Ben Carson, known for his expertise in neurosurgery and famous for the first successful separation of pediatric conjoined twins. More recently, Dr. Kizzmekia Corbett, an immunologist at the National Institutes of Health, was instrumental in developing Moderna’s COVID-19 vaccine. Indeed, we celebrate some of the “firsts,” as in Dr. Rebecca Crumpler, the first African American woman to earn a U.S. medical degree in 1864, or Dr. Joycelyn Elders, who was the first African American and second woman to hold the office of United States Surgeon General. Nurses celebrate Mary E. Mahoney, the first African American person to earn the title of Registered Nurse, in 1879, and social workers laud the impact of Dr. Joy DeGruy, a clinical social worker best known for her work in intergenerational trauma. As we celebrate more accomplishments than can be listed here, we must also confront a health system that was not always fair and just for African Americans in the U.S. Dr. DeGruy’s work in intergenerational trauma originates from her research on Post Traumatic Slave Syndrome and its impact on mental health, lived experiences of racism, healing, and resilience in African American families (Campbell, 2019). Intergenerational trauma in the African American experience frames the conversation about disparities in the health system.

Healthcare disparities are often discussed in the context of external forces that produce disparate systems and outcomes. However, healthcare disparities may also emanate from internal forces within the African American community. Consider some of the symptoms of intergenerational trauma: lack of trust in others, fearfulness, and inability to connect with others (King-White, 2022)—transgenerational means acting across multiple generations. If multiple generations of African American families perceive the healthcare system through the lens of mistrust, fear, or inability to connect with healthcare professionals, a disparate system is created.

In addition to transgenerational trauma-induced mistrust, fear, and disconnectedness borne from the African American experience in the U.S., there is also historical precedence for mistrust and fear originating from medical mistreatment. One of the most famous historical records stems from the Tuskegee Experiment, where untreated syphilis was studied in African American men from 1932, lasting 40 years, through 1972. I was in 5th grade when this study ended, and my parents and grandparents talked about this often. The message, whether overt or implied, from family members, neighbors, and community leaders was “Do not trust the medical system.” Many of my friends were familiar with this study, and I recall the discouragement from members of our community when someone expressed interest in a career in health professionals. I share this personal example to illuminate the importance of “history” in the African American health experience.

Hong (2024) is a social worker who writes about “centering history” in clinical practice to equip clinicians with the skills and tools to provide trauma-informed or culturally sensitive care to African American clients. The idea of “centering history” is a powerful way to promote empathetic, informative care grounded in cultural humility and connectedness. Cultural humility and connectedness are manifested through communication. Intentional communication that strengthens clinician-client relationships is a best practice for case managers.

In addition to effective communication, how can case managers support African American clients and families with challenges stemming from health disparities and intergenerational mistrust, fear, and disconnectedness? I have distilled a plethora of literature sources to five key actions. Cultural competency and sensitivity were already mentioned, but it is essential to engage in recurring training to appreciate the impact of historical trauma and systemic disparities. Four additional actions are:

 

• Address social determinants of health in tangible ways and connect clients to resources that reduce socioeconomic, housing, food insecurity, or environmental barriers to positive health outcomes.

• Develop case management care plans tailored to the needs and preferences of African American clients, incorporating cultural practices, beliefs, traditions, and an appreciation for family dynamics that may differ from one’s own.

• Build connectedness with the African American client and community by participating in health promotion and prevention activities, such as health screenings, vaccinations, and lifestyle support to prevent chronic diseases.

• Advocate for equitable care as a leader who inspires collaboration with interdisciplinary teams and other stakeholders to ensure holistic, coordinated, and comprehensive care.

These action items are in the case manager’s wheelhouse and are consistent with the CMSA Standards of Practice and Ethical Principles. The key is to embody the spirit of lifelong learning, sharpening skills, and incorporating the “history” of the African American experience into clinical practice every day. Michael Garrett, board-certified case manager, strategic healthcare leader, and expert in health equity, will discuss specific examples of how to center the African American “history” in clinical practice while caring for clients/patients with the following:

Sickle Cell Anemia: Sickle cell anemia disproportionately impacts Black patients, including more hospitalizations, sickle cell crises, and blood transfusions (Pokhrel, A. 2023). Case managers can improve the quality and access to care for patients with sickle cell anemia by referring them to centers of excellence, such as the National Alliance of Sickle Cell Centers. Since this is a chronic and potentially fatal disease, it is also crucial for the case manager to understand who the patient identifies as their family of choice since caregivers and family members will likely be involved with the care plan.

Behavioral Health: As pointed out, Black clients have an understandable mistrust of healthcare professionals and systems. However, some studies show that levels of fatigue, stress, anxiety, and depression increased in the Black community during COVID-19 while access to treatment became more complex (Lockett, E., 2023). Some studies show that patient and provider racial concordance can lead to more effective therapeutic relationships, patient experience, and overall better health outcomes (Jetty, A. 2022). The case manager can support an African American client by asking if there is a preference for a racially concordant behavioral health provider. The case manager could also identify other behavioral health professionals and resources that are culturally competent with African American clients, such as Black Therapist List, Therapy for Black Girls, Therapy for Black Men, etc.

Diabetes: A diabetes diagnosis is 77% higher for African Americans as compared to white Americans (Melillo, 2021). This is due to various reasons, including social determinants of health, structural racism, lack of access to healthy and nutritious food, barriers to care, and culturally competent providers (Golden. S., 2021). Although case managers may not be able to impact enhancements in the entire healthcare system in the short term, they can implement practices to support African Americans in managing their diabetes. Since diet is an essential component in managing diabetes, case managers can work with Registered Dietitians in adapting meal planning within the context of the cultural cuisine preferences of the African American client, including identifying ways to access healthy and nutritious food. The case manager can also identify any social determinants of health impacting the care plan, such as transportation to medical appointments. The case manager can also support the African American client in accessing racially concordant healthcare professionals, such as endocrinologists, diabetic educators, etc.

Maternal Health: There have been numerous studies demonstrating significant disparities in maternal mortality and morbidity, including Black women who are at least three times more likely to be due to pregnancy-related causes as compared to white women (Njoku, A. 2023). These differences exist even when controlling for underlying medical conditions, socioeconomic status, and insurance coverage. These unacceptable health disparities could be attributed to systemic racism, lack of culturally competent providers, lack of access to healthcare services, and social determinants of health, among other reasons. Again, the case manager can inquire about the preference for an African American client to seek care from a racially concordant provider. The case manager can also assess and address social determinants of health that are negatively impacting the care plan, such as access to geographically accessible providers, transportation, and healthy and nutritious food. The case manager may also consider whether the African American client is interested in receiving a referral to a maternity doula who could provide support, advocacy, and coaching throughout the birthing process. Some studies show that maternity doulas can positively impact the client’s experience with the birthing process and reduce infant mortality rates and other positive health outcomes (Sobczak, A., 2023). This is especially true for women who are immigrants and who have limited English proficiency. There is a growing movement for Medicaid and commercial plans to cover the services provided by maternity doulas (Chen, A., 2023).

These are just a few examples of how case managers can adapt professional case management practice that respects, honors, and supports the needs of African American clients to support increased access to care, enhanced client experience with healthcare, and improved care outcomes.

References

Campbell, B. (2019). Past, present, future: a program development project exploring post traumatic slave syndrome (PTSS) using experiential education and dance/movement therapy informed approaches. American Journal of Dance Therapy, 41(2), 214-233. https://doi.org/10.1007/s10465-019-09320-8

Chen, A., & Rohde, K. Private insurance coverage of doula care: A growing movement to expand access. National Health Law Program. March 14, 2023. https://healthlaw.org/private-insurance-coverage-of-doula-care-a-growing-movement-to-expand-access-2/  Retrieved 2/9/2024.

Golden SH, Joseph JJ, Hill-Briggs F. Casting a Health Equity Lens on Endocrinology and Diabetes. J Clin Endocrinol Metab. 2021 Mar 25;106(4):e1909-e1916. doi: 10.1210/clinem/dgaa938. PMID: 33496788.  https://pubmed.ncbi.nlm.nih.gov/33496788/  Retrieved 2/9/2024.

Hong, S. (2024). Trauma-informed cultural humility mental health practice: centering history among African American women. Social Work, Volume 69, Issue 1, Pages 64–72. https://doi.org/10.1093/sw/swad045

Jetty A, Jabbarpour Y, Pollack J, Huerto R, Woo S, Petterson S. Patient-Physician Racial Concordance Associated with Improved Healthcare Use and Lower Healthcare Expenditures in Minority Populations. J Racial Ethn Health Disparities. 2022 Feb;9(1):68-81. doi: 10.1007/s40615-020-00930-4. Epub 2021 Jan 5. Erratum in: J Racial Ethn Health Disparities. 2021 Feb 24;: PMID: 33403653. https://pubmed.ncbi.nlm.nih.gov/33403653/  Retrieved 2/9/2024.

King-White, D. (2022) Intergenerational trauma: what it is & how to heal. Choosing Therapy. Online Newsletter. Brooklyn, NY.

Lockett, E. (2023). Why it’s time to shift the focus to mental health in the Black community. Healthline. February 17, 2023. https://www.healthline.com/health/mental-health/mental-health-in-the-black-community  Retrieved 2/9/2024

Melillo, G. (2021). Recognizing the role of systemic racism in diabetes disparities. American Journal of Managed Care. February 2, 2021. https://www.ajmc.com/view/recognizing-the-role-of-systemic-racism-in-diabetes-disparities  Retrieved 2/9/2024.

National Alliance of Sickle Cell Centers. https://sicklecellcenters.org/member_centers  Retrieved 2/9/2024.

Njoku A, Evans M, Nimo-Sefah L, Bailey J. Listen to the Whispers before They Become Screams: Addressing Black Maternal Morbidity and Mortality in the United States. Healthcare (Basel). 2023 Feb 3;11(3):438. doi: 10.3390/healthcare11030438. PMID: 36767014; PMCID: PMC9914526. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9914526/  Retrieved 2/9/2024.

Pokhrel A, Olayemi A, Ogbonda S, Nair K, Wang JC. Racial and ethnic differences in sickle cell disease within the United States: From demographics to outcomes. Eur J Haematol. 2023 May;110(5):554-563. doi: 10.1111/ejh.13936. Epub 2023 Feb 12. PMID: 36710488. https://pubmed.ncbi.nlm.nih.gov/36710488/  Retrieved 2/9/2024.

Sobczak A, Taylor L, Solomon S, Ho J, Kemper S, Phillips B, Jacobson K, Castellano C, Ring A, Castellano B, Jacobs RJ. The Effect of Doulas on Maternal and Birth Outcomes: A Scoping Review. Cureus. 2023 May 24;15(5):e39451. doi: 10.7759/cureus.39451. PMID: 37378162; PMCID: PMC10292163. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10292163/#:~:text=Overall%2C%20it%20was%20found%20that,doulas%20%5B25%2C27%5D.  Retrieved 2/9/2024.

Bios: Melanie A. Prince, is the Immediate Past President of Case Management Society of America (CMSA), 2020 - 2022. She is a retired Active Duty Military Colonel who was assigned to Headquarters Air Force where she was responsible for developing strategies to eliminate interpersonal violence in the military. Melanie is now the Chief Executive Officer, Care Associates Consulting and MAPyourWAY, LLC. Melanie is a certified case manager and medical-surgical nurse with over 30 years of progressive leadership responsibilities and diverse clinical experiences in emergency medicine, inpatient care, disaster management, ambulatory health, population health and medical management. Her excitement and confidence in the principles of case management inaugurated the Air Forces first independent Nurse Managed Clinic staffed exclusively by case managers, where patient outcomes were game-changers for medical management and population health. Recognized for fusing business acumen with clinical expertise to launch award-winning programs, Melanie is considered a subject matter expert in case, disease, and utilization management. Melanie is a graduate of Air University in Montgomery, Alabama, where she earned a Master's Degree in Military Strategic Studies. She also has a Master's Degree in Nursing with a concentration in Case Management from University of Arizona, and a Bachelor's Degree in Nursing from University of Louisiana, Lafayette. Active in professional organizations, Melanie has been elected to local and national leadership positions, as well as appointed to national advisory roles for the CMSA, including Chapter President and Treasurer, National Board Director, Secretary, Public Policy Committee and Case Management Industry Leadership Coalition member, Military Liaison and Advisor to the CMSA National Board. As one of the founders of the DOD/Veterans Affairs Military Day, Melanie launched a forum that brought clinical case managers from diverse backgrounds who served wounded warriors and other clients, into a full day of workshops, collaborations, and professional development. Melanie has been a requested speaker, including annual CMSA conferences, and penned case management content, editorials, policy, and training in various publications both military and non-military. A distinguished leader and mentor in her profession, she has won numerous awards including the distinguished CMSA Chapter, 2003 and National Case Manager of the Year, 2004. Melanie is a CMSA Case Management Fellow (CMF) and Fellow, American Academy of Nursing (FAAN).

Michael B. Garrett, MS, CCM has more than 40 years of experience in case/care management with public and private sector health and benefit programs. For the last ten years, he has focused on improving health equity for historically underserved communities, including assessing how organizations can better support diversity, equity, inclusion, and belonging (DEIB). He serves on the editorial board of Professional Case Management, the URAC health equity council, and he is the current chair of the CMSA™ DEIB committee. He holds a Bachelor of Arts in psychology and religious studies, and a Master of Science in clinical psychology. He is board certified in case management and vocational evaluation.