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The Fifth Aim: Wholistic Health Equity

by Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP on 11/21/20

The five domains of the social determinants of health (SDoH) were recently updated for Healthy People 2030 (HP 2030) (U.S Department of Health and Human Services, 2020):
  • Economic stability
  • Education access and quality
  • Health access and quality
  • Neighborhood and built environment, and
  • Social and community content

I reviewed the revised language of each domain with excitement. It was impressive to see the key terms, "access" and "quality", added to the education and health domains. These terms are especially powerful amid election rhetoric that frames health and behavioral healthcare as a right versus a privilege for all persons. Health and language literacy also received emphasis in HP 2030; each term is now aligned with both education and healthcare domains. These terms contribute to attaining prevention and wellness outcomes across populations. The pandemic has been a solid reminder of the influence health and language literacy each have in minimizing virus transmission. Communities of color and those regions with persons having limited to no English language literacy experienced the highest rates of virus transmission. This fact is due to population lack of trust in, and understanding of public health mandates and infection protocols (Cangussú, et al., 2020; Ramos et al., 2020).

The changes to HP 2030 are critical to advance how the social determinants of health and mental health are managed across the healthcare industry. The presence of quality education and healthcare in any community are essential. However, when access to these resources is hampered by systematic racism, disparities become embedded within every practice setting. Reimbursement, provider and industry stigma, lead to staffing shortages. These disparities impede a patient’s ability to obtain necessary appointments and care reflective of cultural needs and preferences. Quality of care deteriorates as providers become overburdened by grossly expanded caseloads and inadequate time to render care. Reimbursement pales in comparison to what it should be. Clinical and fiscal outcomes fail to meet established thresholds. The industry can and must do better, but how?

These concerns got me wondering about the industry’s quality compass, the Quadruple Aim. The aim has long been viewed as the key to address gaps in care standardize quality of that care across practice settings.  There is fierce industry emphasis to reconcile prevailing health and behavioral health disparities as a means to attain wholistic health equity. Yet how can the industry accomplish this feat? Perhaps it is time for creation of the Fifth Aim, wholistic health equity.

Wholistic Health Equity

The literature is compelling; health and behavioral health are in a synergistic relationship, with disparities a major disruptor of outcomes. A recent study (Wan et al., 2020) focused on ACEs incidence for multiple sclerosis (MS) and other auto-immune diseases. The Childhood Trauma Questionnaire was given to 925 participants across five cohorts that evaluated emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Over 66% of patients endured more than one ACE. Recent demographics for MS reveal a rapidly increasing percentage of onset across racial and ethnic groups, particularly Blacks and Latinx individuals. These patients usually present with increased severity at onset due to limited access to specialists and delays in treatment.

Unconscious, implicit, and explicit bias impact patient engagement, treatment, and ultimately outcomes. Recent research by Takeshita et al., (2020) found that patients are more comfortable and have a higher quality patient experience and level of engagement with practitioners of the same race. A cross-sectional analysis of 117, 589 Press Ganey patient satisfaction surveys were completed from adult outpatient practices of an urban, academic health system from 2014 to 2017. The study revealed physicians among racially and ethnically disdordant patient-physician dyads had significantly lower odds of receiving the maximum patient experience score when compared with concordant dyads (Takeshita et al., 2020). This research is consistent with work by Meyer & Zane (2013) that explored how culture and race of a provider impacted patient responsiveness to care. Minorities valued when their provider was knowledgeable about the ethnic and racial group’s history of prejudice and discrimination. Minority patients engaged with care providers who did not acknowledge or process the reality of living in a racist society, experienced a poorer quality of care.

Other studies reveal how implicit bias directly impacts clinical treatment across persons of color, gender, and other marginalized groups. Blacks and Latinx patients are often prescribed less pain medication than White patients with the same complaints (Lee et al., 2019; Pagán, 2018). Both of these populations, along with female patients, more readily have their physical and mental health symptoms dismissed than White populations (Pagán, 2018).

The Fifth Aim

It is an industry mandate for every organization and practice setting to embrace wholistic health equity as the Fifth Aim. This concept encompasses the following elements:

  • population-focused care that incorporates the wholistic health triad (e.g., pathophysiology, psychopathology, psychosocial circumstances) (Fink-Samnick, 2020)
  • practices attentive to diversity, equity and inclusion across populations, and
  • realistic reimbursement that assures mental health parity and value-based care accountability.

The Quintile Aim stands firmly positioned as the quality compass for the future, promoting patient-centric, safe, equitable care across populations, providers, and profit margins, as shown in Figure 1.

Figure 1: The Quintile Aim (see graphic)

The imperative for this Fifth Aim is validated via the data. However, more importantly, the need to advance the concept is evidenced through every face of unmet patient need experienced from a disparity. A recent blog post (Mate, 2020b) said it best; the health and behavioral health industry can’t improve equity without taking on institutional (and all forms of) racism.

“Yes, improving safety, effectiveness, patient-centeredness, timeliness, and efficiency is difficult, but equity is the most challenging because we never intentionally designed systems to harm patients. We never legislated long waiting times. We never imposed rules, regulations, customs, and norms for ineffective care. We did, however, legislate inequity. It’s in the founding documents of our country. It’s how we built this nation. It’s in our language. It’s in the way that we read and write. It’s in the way that we build our cities. It’s in what we see online.”

(Mate, 2020)

The mandate for the Fifth Aim of wholistic health equity is clear. Only through this effort can the industry address the embedded ethos of systematic racism which disrupts access to necessary and inclusive care for all persons. This expanded approach would also account for the impact of historical trauma on the perception of access to care which impedes access to care for marginalized populations.

Actions Speak Louder Than Words

Operationalizing a Fifth Aim will take more than cultural awareness trainings focused on unconscious bias at organizations (Silvashanker & Mohta, 2020). Promoting wholistic health equity will require the following actions at minimum:

  • Reimbursement for mental health services that is adequate and equitable across private and public insurers.
  • Grant funding leveraged to the fullest as a means to mitigate gaps in care and treatment.
  • Attention to practitioner shortages by expanded provider networks, increased reimbursement, and attention to specialty care needs of BIPOC, LGBTQ+, and all marginalized populations.
  • Treatment beds and space substantiated to assure access to quality health and behavioral health.
  • Access to appropriate, timely, and reflective mental health treatment without appointment delays to maximize stabilization and prescription management.
  • Interprofessional academic preparation and continuing education for providers and practitioners on all types of stigma and biases that disrupt patient care and treatment, with
  • Attention to the impact of trauma and ACEs on illness morbidity and mortality across the developmental stages (e.g., infancy, children, adolescents, adults).

Society may not have intentionally designed systems to harm patients, but that reality has played out repeatedly over time. Wholistic health equity and a meaningful Quintile Aim can achieved through strategic and committed actions. Less rigorous efforts will not be sustainable or optimal. Only then can the industry attain clinically and fiscally appropriate care for all.

This blog first appeared as an assignment for Cummings Graduate Institute of Behavioral Health Studies, DBH: 9016, Fall 2020. #DBH #DBHRocks #SDoMH #wholistichealth #QuintileAIm

Bio: Ellen Fink-Samnick is an award-winning industry thought leader who empowers healthcare's interprofessional workforce. She is a sought out professional speaker, author, and educator for her innovative content and vibrant presence. Ellen is an international national expert on the Social Determinants of Health, Workplace Bullying, Professional Ethics, Professional Case Management Practice, and Wholistic Case Management™. Her recent books include, The Essential Guide to Interprofessional Ethics for Healthcare Case ManagemenThe Social Determinants of Health: Case Management's Next Frontier, and upcoming End of Life for Case Management, all through HCPro. Along with several academic teaching appointments, Ellen is Lead for RISE's SDoH Community and Doctor in Behavioral Health (DBH) candidate at Cummings Graduate Institute for Behavioral Health Studies. View more on her LinkedIn Profile.


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Cangussú, L.R., Pereira de Barros, I.R., de Lima Botelho Filho, C.A., Delmoutiez Ramalho Sampio Filho, J., & Rodrigues Lopes, M. (2020) COVID-19 and health literacy: the yell of a silent epidemic amidst the pandemic, Rev Assoc Med Bras 2020;66(Suppl 2):31-33

Fink-Samnick, E. (2020a) Chapter 8, Health disparities, in End of life care for case management, HCPro.

Fink-Samnick, E. (2020b) The intersection of systematic racism, the pandemic, and sdomh: reality mandates change; ACES Connection. Retrieved from

Fink-Samnick, E. (2020a) Wholistic health equity: bridging the cost, ethos, and quality divide; DBH 9016. Cummings Graduate Institute of Behavioral Health Studies: unpublished assignment.

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Lee, P., Le Saux, M., Siegel, R., Goyal, M., Chen, C., Ma, Y., & Meltzer, A. C. (2019). Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review. The American journal of emergency medicine37(9), 1770–1777.

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Takeshita. J., Wang, S., Loren, A.W., Mitra, N., Shults, J., Shin, D.B., Sawinski, D.L, (2020) association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings. JAMA Network Open. 2020; 3(11):e2024583. doi:10.1001/jamanetworkopen.2020.24583

Ramos, A.K., Duysen, E., Carvajal-Suarez, M. & Trinidad, N (2020) Virtual outreach: using social media to reach spanish-speaking agricultural workers during the COVID-19 pandemic, Journal of Agromedicine, DOI: 10.1080/1059924X.2020.1814919

U.S. Department of Health and Human Services (2020) Social determinants of health, Healthy People 2030. Office of Disease Prevention and Health Promotion; Retrieved from

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