Making sure healthcare isn’t a lottery in rural Nevada. Featuring Debra Toney.

Dr. Debra A. Toney PHD, RN, FAAN, is Vice President of Quality Management at Nevada Health Centers, President of NCEMNA and a past president of NBNA. She discusses her groups approach to population health management in Nevada, a primarily rural population where remoteness is a major factor in health disparities. Dr Toney talks about the importance of social determinants, particularly in the context of FQHC care provision, and how telehealth and mobile units are making a difference to disparities in conjunction with the consistent implementation of evidence-based guidelines and care personalization. Dr Carla Harwell and Dr Toney also discuss the decline of paternalistic medicine and the rise of patients as partners in their own health, and how better engagement can be facilitated by meeting patients where they are.

Episode Transcription

Making sure healthcare isn’t a lottery in rural Nevada.
Featuring Dr. Debra Toney.
[Recorded July 2019]

Carla: You are listening to the Health Disparities Podcast from Movement Is Life. A series of conversations about health disparities with people who are working to eliminate them. Today, I am discussing health disparities with Dr. Debra Toney. Dr. Debra Toney is a past-president of the National Black Nurses Association, hereafter referred to as NBNA, and currently serves as a Director of Population Health Management at Nevada Health Centers in Las Vegas. Welcome Debra.

Debra: So, I am, now, the Vice President of Quality Management for Nevada Health Centers, which, by the way, is the largest, federally qualified community health center in Nevada. So, we have 18 locations.

Carla: Oh, that’s great.

Debra: So, when we talk about population health, we’re talking about populations of people, but all of that falls up under quality management because, again, we’re trying to make sure that people receive high levels of care, that they’re having a high level of quality living, because everybody doesn’t have that.

Carla: Can you give us a quick Population Health Management 101 course and tell us what that is and how does it impact health disparities?

Debra: So, when we talk about population health and, particularly, from my perspective and where I’m at, because of our locations that are throughout the state, we’re talking about individuals who live in various communities, and let’s just use diabetes, for example. We want to make sure that everyone is receiving the same type of care, period. So, when we start talking about algorithms, we often hear with disparities that certain pockets and populations of people receive care that is different. So, when you start talking about population health and tracking, being focused on the social determinants of health, social determinants of health and disparities took on a new name and definition for me when I got involved with FQHC. So, everybody thinks about Nevada being Las Vegas, but it’s not. The majority of Nevada is rural. So, when we talk about ruralness and just the financial impact, the remoteness of frontier cities, those are disparate areas, too, simply because there is a total lack of access. You may have to drive two or three hours to receive cardiology services and some of those other things. So, it really took on a different meaning to me when I start looking at disparities.

Carla: What progress in eliminating health disparities have you seen made in the last year, especially, maybe where you’re talking about in these rural areas of Nevada.

Debra: Well, particularly, with the ruralness, when we start talking about remote access, when we start thinking about things like telehealth. When we start looking at things like mobile units and some of those types of things, I believe that has truly made a difference, but, also, when you start looking at population health and evidence-based guidelines that say, and one of my responsibilities is if a person walks into the office and they have diabetes or hypertension, based on standards and guidelines, this is what I want to see happen with every patient that comes in the door that has diabetes. Now, not saying we’re trying to tell the providers and all of them what to do. Of course, there’re all types of complexities and different little idiosyncrasies that each patient has. So, the providers, then, are able to tweak and customize certain things that way, but if you have a certain disease entity, we want to make sure that certain things are covered that’s evidenced by this is what will improve care, improve health, that type of thing.

Carla: Right. So, these are just your basic standards of care issues that all people should get.

Debra: Your basic standards of care, and then, you’re able to do some of those additional things that it may require because they’ve got some other things that they’re dealing with. So, whether we’re talking about social determinants of health, whether it’s financial, whether it’s literacy, all of those types of things. And then, education, what I’ve found, is huge in just trying to get people on track and understanding, really, what’s happening with their own health.

Carla: Which leads me into my next question. How can we get patients to be more involved in this process of eliminating disparities?

Debra: You know that’s the hundred-dollar question.

Carla: Absolutely.

Debra: One of the things that I’m confronted with on a daily basis is the whole education piece. What I find in educating patients and getting patients to understand, you really have to gain the trust. So, oftentimes, we feel that you go into a provider office, a medical office, and just because I’m the doctor or I’m the nurse practitioner, I have all the answers, but, most of the time, patients don’t trust you. People have the opportunity to go online, they want to ask a bunch of questions, but there has to be that relationship. So, we often hear, people don’t care how much you know, they want to really know how much you care. So, one you can put some of those types of things in place, and there’s just a whole algorithm, you know, patient experience and patient engagement is huge. So, it’s not any difference than going to a grocery store and the bread is stale. You’re not going back to that grocery store. So, if your experience in your provider office and if you don’t trust and you’re not listening, then, they’re going to shop around and find what it is they truly need.

Carla: Yes, I tell my own patients all the time, long gone are the days of Marcus Welby type medicine. It’s that paternalistic medicine where, whatever the doctor says that’s what I do, and he has my best interest in mind. And so, like you said, patients are more educated, now as they come into the office and, if they’re not, that’s exactly one thing that we need to try to push.

Debra: Yes, they’re definitely more educated. They have smart phones and just a whole host of things that they’re able to look up, do their own research and that type of thing, and then, they’re coming back with questions and looking for some answers, too. It truly makes a difference and, you know, I think empowerment and being able to empower patients to challenge the status quo because patients know what makes them feel better. They know what their own personal goals are. So, now, with computers and all of those types of things, I often hear patients say, “Well, I’m going to answer all these questions that you’re asking me, but, now, that’s what you wanted me to do. So, now, this is what I need. So, that ten minutes you just had that was your ten minutes. Now, where’s my ten minutes.”

Carla: Absolutely. That’s good. That’s good. So, you talked a little bit about what patients can do. What about professionals?

Debra: Professionals, I think, again, goes right hand-in-hand in what we talked about in being able to introduce yourselves. Again, it’s about the experience. It’s about patients being satisfied, and then, asking. You know, I always use the analogy of I cook. So, here in New Orleans, there’s a whole different thing here with all the food and the good food and those types of things, but I’m going to just use the greens analogy. Being an African American and we have these huge issues with high blood pressure, etc., how many of us have not cooked greens with salt pork and all of those type of things in there. But, now, you can put some smoked turkey in there and it tastes just as good, but you have to be able to navigate that and negotiate that with patients, and not expect patients to do things, just cold turkey. “I need you to think about not smoking anymore. How many packs are you smoking?” “I’m smoking a pack.” “Well, can you smoke ten instead of the whole pack?” You have to be able…patients want to know that you understand how difficult change in behavior is. So, healthcare professionals, we’ve got to be able to do that and just, kind of, slowly, work with patients and meet them where they’re at and not, necessarily, think that they’re always going to show up at our place of business, but we have to just think about how flexible are we and how, if we truly care about the patient, again, it goes back to that, if you really care about me. You can’t have banker’s hours and just a whole host of things. You’ve got to be flexible and meet the patient where they’re at and slowly move them to that area where, then, they’ll say, “Oh, wait a minute. I lost two pounds. Maybe I do need to think about not having so much butter and try some of these other little things.”

Carla: So, you’ve hit on value-based care. That’s what it’s about. It’s about the patient’s experience and professionals need to be able to be onboard, like you said, to meet the patient. Not halfway, but all the way.

Debra: All the way.

Carla: To see what all is incorporated into that person and that person trying to do the right thing in terms of their healthcare.

Debra: Yes, because they are trying.

Carla: They are trying, absolutely. I don’t believe anyone wakes up and says, “I want to be as sick as I can possibly be this morning and not take any of my medicines.” Right?

Debra: I agree with you.

Carla: The social determinants of health are things that sometimes prevent that from happening.

Debra: Yes, yes.

Carla: Well, we have a few minutes remaining and I’d like to ask you, as a past-president, of NBNA, what would you say are some of the big changes impacting membership and patients, when it comes to health disparities, and what are your hopes for future progress?

Debra: You know, I think we’ve made a lot of progress. As a past-president and being able to advocate, to teach people how to advocate for themselves and that it’s okay for them to challenge the status quo. And, nurses being the largest profession. There’s four million of us. NBNA has a whole bunch of those nurses in our organization. But being involved in the community. You know, when we heal communities, we’re healing populations and then, we are, actually, healing the nation. So, I think it’s all of those types of things and being able, as nurses, to advocate. Sometimes, we have to take off the hat, take off the uniform and then, we have to go to Capitol Hill and really, advocate for those things that are most important that we know is important for our patients. So, I think there’s a lot has been done, but there’s still a whole lot more because disparities are real. They do exist. They exist in rural communities. They exist in poor communities. And, it’s up to us to make sure that that’s eliminated.

Carla: That’s great and thanks to people like you and the wonderful organization that you’re a part of that we’re helping to try to push that needle closer to the elimination of these health and healthcare disparities. Well, thank you, Debra and thank you all for listening to the Health Disparities Podcast from Movement Is Life. Please join us for new installments every two weeks by subscribing at Apple Podcast, Stitcher, Spotify, and Google. You can also find us at Thank you and see you next time.

(End of Podcast)

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