Patient-Provider Dialogue:  The Importance of Guidance
Carolyn Clancy, M.D.

Improving the quality, safety, efficiency and effectiveness of healthcare for all Americans is the top priority and mission for the Agency for Healthcare Research and Quality (AHRQ) and for Director, Carolyn Clancy, M.D.   Dr.  Clancy shares the progress of the organization and describes patient-centered care as one of the most challenging of all six Institute of Medicine domains of quality. In her presentation, Clancy reports that the quality of care improved slowly for the general population from 2002-2008.   However, limited health literacy continues to pose a problem for quality and is linked directly to poor health outcomes.   AHRQ has defined health literacy as one of their key initiatives and has funded several projects to support better outcomes.

Projects include: Project RED-a re-engineered discharge communication project with Boston University Medical Center-aimed at improving patient safety by recreating the process by which patients leave the hospital. A web-based toolkit to help adult and pediatric primary care practices implement health literacy measures. An informed consent and authorization toolkit to ensure inclusion of low literacy populations in research and secure that consent and authorization is truly informed.

Direct outreach to patients is also a key initiative, including efforts to develop:

• A multimedia campaign to explore treatment options and encourage patients to become more informed.
• Traffic to the AHRQ website for unbiased information about treatment options.
• Better patient/provider discussion by planning treatment goals for visit.
• Video to help people understand how to take blood thinners safely.
  

Patient centered outcomes research and national healthcare quality strategy is another top priority including:

• Providing health educators with treatment options that are based on evidence and information on effectiveness, benefits and harms.
• Developing plain language materials with multiple delivery options and languages.
• Engaging patients through goal-planning and teach-back methods.
  

In closing her presentation, Dr. Clancy states that the status quo is not an option.  As a country, we need to focus on accessibility for all; patient-centric dialog; delivery by a well-prepared work force; effectiveness at preventing disease and improving health, and transparency.

Moving Upstream: Creating a Public Health Literate Society Darcy A. Freedman, Ph.D., MPH Dr.  Freeman's presentation emphasized the need to situate health in a much broader "upstream" context that includes social, political and economic factors.  The current model, she says, is more about "sick care" than health care.   It is focused on treatment, and there are a few key players:  patients, clinicians, hospitals, clinics and the health insurance industry. But, she says, health is not just a matter of individual biology and genes.  There is a "both/and" model that includes only individual factors, but "upstream" ones as well.   She offered the example of breast cancer, where biological factors, the genes that make you vulnerable to breast cancer are "switched on" by social, economic environmental factors, like stress, poverty and toxins in the environment.  She offered a broad spectrum vision of healthcare, a "cells to society" framework, one that addresses the question, how do social factors get "into our skin?"   She asked us to imagine how we might respond if our health care dialogue included a number of startling statistics, such as the fact that "deaths attributable to low education is comparable to the number caused by acute myocardial infarction (192,898), a subset of heart disease, which was the leading cause of death in the United States in 2000." Dr.  Freedman spoke of three dimensions of public health literacy: conceptual foundations, critical skills, and civic orientation.   She offered the concept of collective health literacy:  that is, no single person needs to have all knowledge.   Some may, for example, have conceptual rather than formal or statistical knowledge.   She spoke about a community foundation in Nashville which had a high level of conceptual knowledge, based on personal experience of its members.   They had, she said, an ecological understanding of health that allowed them to include a community garden in their concept of a healthcare system. A federally qualified health center in North Carolina noted high rates of diabetes and obesity in their community.   The clinic staff conceptualized the local farmer's market as a pharmacy; treated farmers as if they were health care providers, and developed a" prescription" for farmer's market vegetables. They included the economic situation as one of the multiple determinants of health.    Dr.  Freedman also included critical skills, such as knowing who is in charge of naming and framing the debate, in the concept of public health literacy.  Critical skills were present when a neighborhood was able to articulate and demonstrate the need for a supermarket in their neighborhood.  Being able to say that "where we live, learn, work, and play can have a greater impact on how long and well we live than medical care, " is an example of critical skills. Dr.  Freedman included civic orientation as an essential part of public health literacy.   She defined it as "ensuring that "the public" remains at the center of public health literacy and includes the skills and resources necessary to address health concerns through civic engagement.   She offered several other examples of projects that built upon civic orientation. In closing, Dr. Freedman recommended an "explode the issue" activity that helps to alter the mindset of "this is just the way things are."  You can ask, "why does this exist?" and then continue to ask the same question of each answer, in order to expand strategies of intervention. The Case for Collaboration:  Creating and Sustaining Healthy Partnerships Beth Ruland; Beth Gayton Beth Ruland manages Community Health Improvement Partners' (CHIP) access to healthcare programs and efforts, including Health Literacy San Diego.  Beth Gaytan is the Health Literacy Director of Literacy Network of Dane County.   Each spoke about the ways in which their programs engage in and benefit from collaboration.  There was a very high level of interest in their talk, judging by the many questions from the audience at the end of the session. Beth Ruland spoke first about the collaboration between CHIP and The San Diego Council on Literacy.   She described an ideal task force as one that brings different perspectives and common opportunities to the table where CEOs and consumers have equal say.  She talked about the three key elements of a successful collaboration:  having a common goal and a strong mission; reciprocity among members; and good communication.   Communication included the following: Goals and objectives clearly communicated to the task force Updates to committees Acknowledgement of contributions and successes She also outlined the competencies needed for a successful collaborative: Mission leader Resource manager Facilitator/expert/consultant Program coordinator Infrastructure manager Community leader And, she noted, it is difficult to move forward without staff.

Beth Gaytan gave a brief history of the English for Health partnership in Wisconsin, which included the Latino Health Council, St.  Mary's Hospital, UW School of Pharmacy and the Willy Street Co-op.  They began with nine employees and ABE and ESL classes.  They learned from their students that they were not healthy, and were afraid to go to the doctor.  Students also wanted to learn to use medicines safely and how communicate with providers.  The end result of this early step in the collaboration was to develop a mock clinic. English for Health started specifically with St. Mary's.  St.  Mary's provided a room in their hospital two evenings a week for 12 weeks.  Clients had to navigate the hospital to get to class and employees began to notice the students.  The RNs who participated had positive feedback.  They felt that in the un-rushed setting of a mock clinic students asked many more questions.  In addition, they learned from the students themselves.  So, there was great value to employees who come to classes.  The providers understand what it is really like-they get to ask questions they couldn't ask in a clinic setting.  Nursing students began to request students to come to their classes so they could ask questions like how clients wanted doctors to talk to them through interpreters.  The students loved doing it and were well reimbursed for their time.  Med students are now part of the rotation-they get expertise and practice through role plays.    As a result of the first class and the positive feedback, a group existed within the community who understood what the Literacy Network was doing, and they were able to reach out to the broader community.   Pretty soon, other organizations were calling and asking to participate. Ms.  Gaytan spoke about several key steps.    One key is to have very specific goals, a specific start date and end date, so that it doesn't become a lot of work for the clinics. Secondly-- get community endorsement, which involved many, many meetings, before there was any immediate benefit-maybe a year and a half before the classes were actually implemented. Keep track of, stress, and advertise the positives, and in doing so, you can make your partners look good.   An example was when the mock clinic at St.  Mary's was on the news, which brought very positive attention to St.  Mary's, and increased their interest in supporting it. Other keys to success included advance planning, community visibility, joint leadership and leadership support, involvement of the receptionist in the clinics, and provision of child care for students.  English for Health is now in 3 hospitals and 11 clinics. Ms.  Ruland emphasized that her job as manager is to help collaborators understand how health literacy can further their efforts.   She acknowledged that collaborations are difficult to manage and sustain.   In order to do so, she said, you must make sure of the following: All partners are getting value Everyone is contributing in a meaningful way Everyone has a clear understanding of work plan and what partners are expected to do Use interests, expertise and skills of members Talk to members, see what they are thinking Actively recruit new members Make it as easy as possible to participate Collaborators must also make sure that they can measure the success of their efforts-that is, evaluate what you do in your collaboration.

Panel: Health Plan Health Literacy Tools Alisha Ellwood, MA, LMFT; Lenna Monte, MPH, CHES; Jeannette Mallery, MA Assessing health literacy in your practice can be an eye-opening experience, states Alisha Ellwood MA, LMFT of Blue Cross/Blue Shield of Minnesota.   An assessment tells you what's working well, uncovers things you didn't know and highlights opportunities for improvement.    In this three part presentation; Ellwood opens by sharing keys to developing and implementing a successful assessment program and provides examples of existing tools.    In developing an assessment program, Ellwood recommends: Selecting an existing assessment tool Identifying several people to complete the assessment questions Share and discuss assessment results Using results to create an action plan with clear and measurable goals Re-assessing-using the same tool Next, Leanna Monte, MPH, CHES, of L.A. Care shared the Readability and Suitability Checklist that is used as an assessment tool by their organization.   The checklist assessment tool provides a process and organization-wide standard for developing communication to members.   To ensure that member communication is developed at or below a 6th grade reading level, L.A. Care also runs electronic content through a software program.   Although multiple software options are available, L.A. Care recommends using the SMOG and/or Fry Graph formulas. In her segment of the presentation, Monte recommends field testing for materials which are developed, adapted or obtained from outside sources (with the exception of some).   Field testing should be provided by a qualified health educator who can oversee the field testing process. Field testing may include: Simple review during a Community Advisory Committee or other member event Key informant interviews with members and/or community Focus groups with targeted members Written member surveys Testing development from an outside vendor or organization Tips for organization-wide efforts include: Developing de-centralized ownership of developing easy-to-read materials Making use of authorities within your organization Allowing time for adoption of initiatives within your organization Initial and ongoing education for staff Jeannette Mallery, MA of Aetna Medicaid closes the presentation by talking about the importance of health literacy within your organization.  Mallery states that you may experience organization-wide challenges such as competing priorities, barriers and lack of understanding around the importance of health literacy.   Mallery recommends finding "champions" within your organization that will be advocates in supporting the value of implementing a health literacy initiative.   Forming a cross-functional team of "champions" will help to bring leaders together in a structured and focused way-keeping the health literacy message alive and top-of-mind. Advancing Social Media: Using New Media Tools to Reach People with Health Information Michelle Samplin-Salgato, MPH; Jennie Anderson, MS Social media is changing our world.  Michelle Samplin-Salgato, MPH and Jennie Anderson, MS of John Snow, Inc., challenge us to think about how we can use social media to respond to public health issues.   Salgato states that the first step is to get involved on a few social media outlets.  Sign up and start learning, connecting with others and collaborating.  As subject matter experts in the social media dialog on AIDS, Salgato and Anderson know all about this.  Salgato explains that they look to engage their audience by hosting conversations and being a source for information and support.  "We ask for feedback and express gratitude," states Salgato.  "Then, we wait, and we listen."       Anderson presents the second chapter of the discussion on developing a social media strategy.   In outlining your strategy, you need to start by answering a few key questions: People-who are you trying to reach?  What do you know about how/if they use new media?  How can you find out more?  Start by understanding your audiences use and need for new media. Objectives-what do you want to accomplish with your new media?  Decide on your objective(s) before you decide on the new media tools.   Does you project seek to hear from your audiences, train them, exchange ideas, or collaborate with them?  Consider how you'll measure the success of each objective. Strategy-how will your strategy be met?  How does new media support your objectives?  How does it support your other online activities?  Is there an online component that you need to support/connect?  How will you get your project to embrace a new media strategy? What resources do you have to implement and maintain your strategy?  Strategy results in a plan to meet your objectives, and considers your overall communication strategy, and organizational culture/resources. Tools/Technology-what tools best support your objectives and match your intended audience's needs?  How many hours do you need to allocate this tool?  A wiki.  A blog.  A podcast.   Testing.  Google alerts.  Once you know your people, objectives and strategy, then you can decide what tools will work best in the context of your organization/project's resources. Next, how do you measure your results of new media?  Consider measuring before and after metrics: Before What did you plan to do? What did you think would happen? After What actually happened? How could you have improved? What did your audience think? What will you do differently next time? In closing, presenters Salgato and Anderson challenge the audience to take the next step: For your program and organization-listen to your clients and communities-ask them how they use new media tools. For you-try one new media tool to "listen" and use social media tools to connect. For all (as a network): Find and listen to your peers online What you discover may change your world.

Developing a Health Literacy Program Evaluation Plan Sabrina Kurtz-Rossi, M.Ed. Ms.  Kurtz-Rossi began with making a distinction between evaluation and research.   Research looks for causal links and adds knowledge to the field, whereas evaluation is for program improvement, for people doing the work in the field. Ms.  Kurtz-Rossi identified three different types of evaluation:  community assessment, outcome assessment and process assessment.   She offered purpose and method for each, as well as case examples along the way.   Descriptions and distinctions between different methods (such as key informant interviews, focus groups, existing records, surveys and story-based evaluation forms) and when they are most useful, were very helpful. Kurtz-Rossi discussed five steps to program planning, regardless of the type of evaluation chosen, She advised that starting with evaluation as part of your program from the beginning is more useful than looking for an evaluator at the last minute.

The five steps are as follows:   Know your audience Identify goals and objectives Develop program and evaluation plan Implement and evaluate Apply and share results Step 3 included two valuable exercises in creating logic models, and creating smart objectives.  Much of the time was taken up by audience participation in and discussion of these exercises, for which audience members were asked to employ examples from their own work.   Kurtz-Rossi described logic models as living breathing documents, road maps that are always changing and advised the audience not to be afraid of changing the logic model as a project develops.   She also discussed measurable objectives in helpful detail before asking the audience to practice creating their own.   Her slides were clear and simple and helped to provide useful distinctions and kept the focus on the reasons why evaluation is important and valuable. Ms.  Kurtz-Rossi ended by encouraging the 5th step:  applying and sharing results.   Evaluation is most useful if, if fact you make changes based on what you learned and replicate what you have done, as well as sharing your findings with partners and colleagues.

"Using the Arts to Advance Health Literacy" Andrew Pleasant, Ph.D., Canyon Ranch Institute; Andre de Quadros, Ph.D., Boston University Using an innovative approach to advance health literacy in a small shantytown in Lima, Peru is not an easy task to manage.  But, Dr's Andrew Pleasant (CRI) and Dr. Andre de Quadros (Boston University) did it by teaming up with The Clorox Company to create "Art for Behavior Change (ABC)".  ABC is a program that incorporates health literacy, public health, and the arts.  This is made possible through a partnership with Boston University's College of the Fine Arts.   The team worked in a small "shantytown" in Lima, Peru.  The living conditions they saw were not ideal.  Families live in small cottages that are right next to each other.  Many of the people living in the community hold multiple jobs just to make ends meet.  Their homes had unstable roofing and plumbing.  Presenters Andrew and Andre described entering into a house and immediately smelling the odor from all the waste that is in the home.  They described what it was to walk in their homes.  A small hole can be found in the entrance of the homes that is used to dispose of all the waste (liquid, decal, and trash).  Adults, children, and even animals walk through the fecal matter and waste when in the home, very unsanitary.  Outside of their homes are large blue containers in which those who could afford water would receive it.  The water arrived in a large truck perhaps twice a week and when it arrived, it was already contaminated.  Both doctors were ready to take on take on the challenge of trying to decontaminate the area.  However, they know that would not solve the larger problem of a low health literacy status for this community.   The team developed a series made up of 12 sessions to incorporate personal hygiene such as basic hand washing routines to hygiene in the home.  The goal of their study was to increase health literacy and improve the overall health status of low-income communities.  Students from Boston University's College of the Arts department were recruited to be actors in the 12-part series that included dancing, acting, and singing.  They developed a "tele-novela" style approach to capture the communities' interest in the program.  Using story-telling in a play setting, the program was able to communicate important health messages to the community.  With parades in the street, announcements using megaphones and incentives, the program was able to maintain a stable attendance rate.  No script was formally written so actors developed the script with the help and participation of community members.  The act would pick up where it left off the previous day in which actors from Boston University would actively engage community members to come up and either demonstrates a health behavior, dance or sing.  Community members were awarded with an incentive for their efforts.   This innovative approach in communication successfully changed both short and long-term behavior for a community that was in desperate need of better health outcomes.