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Introduction

The United States has experienced vast demographic changes, especially in the last generation; new populations have emerged as immigrants disperse across the country and form new communities in different states. Such demographic shifts affect health care in a variety of dramatic ways, particularly in the way health care is delivered. With more diverse cultures and languages, health care providers now must tailor the health care they provide to individuals to ensure that care is equitable and patient-centered. Delivering equitable health care and focusing on the individual has incidentally elevated health care disparities and health literacy as major health care topics. Providers are beginning to use tools to improve care delivery in these areas, such as providing patients with appropriate medication instructions in their primary language and offering translation services—tools that could lead to vast improvements in the care patients receive. Quality improvement, with a focus on reducing health care disparities and enhancing health literacy, is vital to assuring better health for the nation now and for future populations.


Ignatius Bau, J.D.

The California Endowment


Health care issues are important to the national dialogue. Unfortunately, the emphasis of this dialogue has focused on issues of insurance and coverage in the reformation of health care with little



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1 Introduction The United States has experienced vast demographic changes, especially in the last generation; new populations have emerged as immigrants disperse across the country and form new communities in different states. Such demographic shifts affect health care in a variety of dramatic ways, particularly in the way health care is deliv- ered. With more diverse cultures and languages, health care pro- viders now must tailor the health care they provide to individuals to ensure that care is equitable and patient-centered. Delivering equitable health care and focusing on the individual has incidentally elevated health care disparities and health literacy as major health care topics. Providers are beginning to use tools to improve care delivery in these areas, such as providing patients with appropri- ate medication instructions in their primary language and offering translation services—tools that could lead to vast improvements in the care patients receive. Quality improvement, with a focus on reducing health care disparities and enhancing health literacy, is vital to assuring better health for the nation now and for future populations. Ignatius Bau, J.D. The California Endowment Health care issues are important to the national dialogue. Unfor- tunately, the emphasis of this dialogue has focused on issues of insurance and coverage in the reformation of health care with little 

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 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS discussion of quality, disparities, and health literacy. Race, gender, class, and age can define us as well as divide us. Yet, to improve quality, reduce health disparities, and enhance health literacy, the principles of equity and patient-centeredness in health care must drive the discussion of health care reform. The reports To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the st Century (IOM, 2001) focused attention on the need to improve the quality of health care in the United States. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (IOM, 2003) explored the ways in which race and ethnicity are significant pre- dictors of the quality of health care received. This report also high- lighted the importance of not exacerbating the health disparities that do exist in the pursuit of quality. Finally, Health Literacy: A Pre- scription to End Confusion (IOM, 2004) highlighted the importance of health literacy to health outcomes and the provision of high-quality health care and illustrated the need for communication in the health care context that is clear and effective. Together, these reports illus- trate that reducing health disparities and improving health literacy are important components of increased quality in health and health care for the American public. While the reduction of health care disparities focuses on popula- tions experiencing and suffering from inequities, its impact is much broader. Interventions to improve access to care and quality of care for populations experiencing the greatest disparities can also posi- tively affect others. For example, ramps for the disabled can also be used by those pushing strollers, and large print and more “plain English” signs and labels are beneficial to those with vision impair- ments and low health literacy, thereby benefiting us all. Ultimately, reduction of health care disparities requires that prevention of dis- ease and morbidity be addressed, requiring broader and longer-term interventions at the population and community levels. Similarly, many interventions that address the needs of specific populations can benefit other populations, as providers can learn to adapt these skills in the care of all patients, allowing for clearer, more effective communication and increased patient understanding and engagement in their own treatment and care. Efforts to make the health care system more equitable can therefore benefit the whole population, not just targeted populations. Achieving equity requires changes at the systems level not for the purpose of segregating the population but rather for the purpose of respecting patients’ cul- tural, spiritual, and religious beliefs and individual needs. To examine the role of quality improvement in improving health

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 INTRODUCTION literacy and reducing racial and ethnic disparities, as well as geo- graphic disparities, the Institute of Medicine Forum on the Science of Health Care Quality Improvement and Implementation, the Roundtable on Health Disparities, and the Roundtable on Health Literacy agreed to collaborate on a workshop. A planning commit- tee1 consisting of members of the three convening bodies as well as other experts in the field organized the workshop, Toward Health Equity and Patient-Centeredness: Integrating Health Literacy, Dis- parities Reduction, and Quality Improvement, which was held on May 12, 2008. THE WORKSHOP AGENDA The workshop began with the presentation of a vision for inte- grating disparities reduction, health literacy, and quality improve- ment to achieve better outcomes, followed by a panel of speakers who addressed building a foundation for integration of these three areas. A second panel addressed using quality improvement as a tool to improve health literacy and reduce disparities at the practitioner level. During the afternoon, breakout groups met and reported back on their discussions of three questions: • What specific activities could be undertaken to effectively integrate quality improvement, disparities reduction, and improved health literacy? • How can such integration be more patient-centered? • What systems integration and systems changes might be nec- essary to achieve greater patient-centeredness and equity? A third panel discussed policy issues related to integration, including standards and priorities that could foster improvement in patient-centered care and equity; types of measures that could be developed to understand the contributions of health literacy and disparities reduction to improved quality; how efforts at integration could be evaluated; and issues of financing, education, and training. The workshop concluded with remarks from the chairs of the three convening bodies. The following is a summary of the presentations and discussion of the workshop and, as such, is limited to the views presented and 1 The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop.

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 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS discussed during the workshop. The broader scope of issues pertain- ing to this subject area is recognized but could not be addressed in this summary. Appendix A is the workshop agenda and Appendix B lists workshop participants.