Toward Health Equity and Patient-Centeredness Integrating Health Literacy, Disparities Reduction, and Quality Improvement: Workshop Summary (2009) / Chapter Skim
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3 Building the Foundation for Integrating Health Literacy, Disparities Reduction, and Quality Improvement in Health and Health Care
3 Building the Foundation for Integrating Health Literacy, Disparities Reduction, and Quality Improvement in Health and Health Care
Pages 17-40
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From page 17... ...
Developing strategies to address low health literacy and its impact on health is problematic, partly because it is very difficult to untangle the contribution of literacy issues to health outcomes from many disparities issues. For example, the relationship between levels of education and health has long been known; research has established a link between low levels of education and poor health outcomes, including a greater mortality risk (NCHS, 1998; Lleras-Muney, 2002; IOM, 2006)
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From page 18... ...
Importantly, the study also found that poor health literacy is a stronger indicator of mortality risk than overall years of schooling. Data from the National Health Literacy Survey of 1992 and the 2005 National Assessment of Adult Literacy show that African Americans and Hispanics are overrepresented in the lowest levels of literacy proficiency (Kutner et al., 2006)
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From page 19... ...
More recent research has examined whether literacy may be a mediating factor in health disparities, thus helping to explain poorer health outcomes for racial and ethnic minorities. When health literacy is taken into account, there is a 25 to 30 percent reduction in the relationship between race/ethnicity and health outcomes, Wolf said.
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From page 20... ...
20 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS Percent Distribution of Handwritten Sig Messages in a Public Hospital 50 45 40 35 30 25 20 15 10 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Percent Distribution of Electronically Generated Sig Messages in an Academic Practice 50 45 40 35 30 25 20 15 10 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 FIGURE 3-2 Variation in prescription instruction. Greater variation occurs in the nonstandardized system (top graph)
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From page 21... ...
. Physicians are routinely reported to be the most trusted source of health information and, for patients with low health literacy, the prescribing physician may be the only source of health information.
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From page 22... ...
Call to Action The thrust for action in quality improvement should target four areas: patient skills, health materials, clinician skills, and health care system design. For patient skills, it is necessary to determine the knowledge patients need to effectively engage with the health care system.
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From page 23... ...
INTEGRATING HEALTH LITERACY, DISPARITIES REDUCTION, AND QUALITY IMPROVEMENT Cindy Brach, M.P.P. Agency for Healthcare Research and Quality There are a number of ongoing conversations that focus on whether cultural competence is a part of health literacy or vice versa.
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From page 24... ...
Strategies for Connecting Health Literacy and Health Disparities One strategy for addressing health literacy and health disparities in the context of quality improvement is to develop specific quality improvement projects that address both issues. For example, an organization might choose to embark on a quality improvement project aimed at improving health education materials.
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From page 25... ...
Another strategy for addressing health literacy and health disparities is to integrate health literacy and disparity reduction into all quality improvement activities. This addresses the concern expressed by some that quality improvement efforts could actually increase disparities.
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From page 26... ...
Once the data have been collected, the next step is to use those data to identify disparities, to tailor the delivery of care to specific populations, and to describe the care being delivered. Another source of quality improvement data can come from CAHPS. These instruments are used in the annual NHDR to mea CAHPS -- The family of CAHPS surveys and tools, housed at the Agency for Healthcare Research and Quality, are used in a variety of health care delivery settings to assess patient experiences of care, to provide reports on performance, and improve health care quality (AHRQ, 2008c)
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From page 27... ...
Brach concluded by presenting a list of tools that can be used to address disparities and health literacy in quality improvement. The AHRQ and Center for Medicare & Medicaid Services guides for culturally and linguistically appropriate services were developed to assist health plans with their quality improvement activities.
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From page 28... ...
childName=&parentCategory Name=&parentCategory=&productId=prod106 0004&categoryName=&prodId=&start=&paren tId= Agency for Healthcare Research and • Strategies to Improve Communication • www.ahrq.gov/qual/pharmlit/ Quality Between Pharmacy Staff and Patients pharmtrain.htm • How to Create a Pill Card • www.ahrq.gov/qual/pillcard/pillcard.htm Health Resources and Services Unified Health Communication (health www.hrsa.gov/healthliteracy/training.htm Administration literacy, cultural competence, limited English proficiency)
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From page 29... ...
Department of Justice, Civil Rights Limited English Proficiency: A Federal http://www.lep.gov/ Division Agency Website Disparities Agency for Healthcare Research National Health Plan Collaborative http://www.chcs.org/ and Quality, Robert Wood Johnston NationalHealthPlanCollaborative/index.html Foundation, Center for Health Care Strategies, and RAND Corporation Agency for Healthcare Research and National Healthcare Disparities Report • http://www.ahrq.gov/qual/qrdr07.htm, Quality • http://nhdrnet.ahrq.gov/nhdr/jsp/nhdr. jsp American Public Health Association Health Disparities Database http://www.apha.org/programs/disparitiesdb/ Health Research and Educational Trust HRET Disparities Toolkit: A Toolkit for http://www.hretdisparities.org/ Collecting Race, Ethnicity, and Primary Language Information from Patients Continued 29
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From page 30... ...
id=1851&subm= Immigrants information) 178&area=Participate Health Literacy and Patient Safety Agency for Healthcare Research and Questions Are the Answer www.ahrq.gov/questionsaretheanswer/index.
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From page 31... ...
National Patient Safety Foundation Partnership for Clear Health http://www.npsf.org/pchc/ Communication Literacy National Institute for Literacy The Adult Literacy Education Health http://wiki.literacytent.org/index.php/Health_ Literacy Wiki Literacy National Literacy Coalition http://www.national-coalition-literacy.org/ about.html Reach Out and Read http://www.reachoutandread.org/ 31
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From page 32... ...
The National Library of Medicine introduced the term patient-centered to its Medical Subject Headings. Finally, in 2001, the IOM defined patient-centeredness as "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" (IOM, 2001)
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From page 33... ...
Furthermore, patients with lower health literacy ask fewer questions of their physicians in observed medical encounters (Beach et al., 2006; Katz et al., 2006) and are more likely to be seen by physicians as desiring a less active role in their health care, despite the fact that these patients prefer to be just as involved as those with higher levels of health literacy (Beach et al., 2006)
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From page 34... ...
Patient-Centered Quality Improvement Interventions There are examples of quality improvement interventions designed to specifically reduce disparities and improve patient– provider communication. For example, there are three randomized controlled trials that are funded by different agencies and that are in three different disease areas: the Coached Care for Diabetes Program, funded by the Robert Wood Johnson Foundation; the Patient– Physician Partnership to Improve High Blood Pressure Medication Adherence (PPP)
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From page 35... ...
A medical home "is not just a building, house or hospital, but a team approach to providing health care. A medical home originates in a primary health care setting that is family-centered and compassionate.
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From page 36... ...
However, considering these issues separately may emphasize their importance to patient-centered quality improvement efforts. Such efforts have the potential to reduce disparities by raising health literacy levels and targeting both the interpersonal (e.g., patient–provider)
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From page 37... ...
Brach responded that there are several projects intended to use patient experiences as a mechanism for increasing health literacy. For example, the adult literacy community is working with providers to arrange field trips to provider offices so that adult learners can increase their knowledge.
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From page 38... ...
Perhaps public health methods are more relevant than the medical home for addressing issues of health literacy and health disparities. Isham responded that the current models for a medical home are not robust enough to address the need for integration of health literacy, disparities reduction, and quality improvement.
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From page 39... ...
Currently, communication about integrating health literacy and disparities reduction into quality improvement efforts is not crossing the chasm to these other components of the health care system. Isham responded that training future professionals is not enough.
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