Toward Health Equity and Patient-Centeredness: Integrating Health Literacy, Disparities Reduction, and Quality Improvement: Workshop Summary (2009)

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4 Integration at the Practitioner Level PANEL INTRODUCTION John C. Lewin, M.D. American College of Cardiology Gaps in health care have been reduced. Reducing these gaps begins with measurement shining a light on behavior changes using, for example, practice guidelines, performance measures, and appropriateness-of-care measures. These are all examples of suc- cessful tools used to improve the quality of care in cardiovascular medicine. Despite advances in care delivery, however, racial and ethnic biases are still problems that must be addressed, as are access to care, cultural competency, and health literacy. The challenge is to apply lessons learned from improving quality in inpatient settings to outpatient settings to better address health care disparities. The American College of Cardiology (ACC), a 37,000-member organization, has taken a great interest in the issues of health dis- parities and health literacy. Fifty-four percent of its members have electronic health records in their offices, a necessary tool for the application of evidence-based clinical decision making. To assist in measuring performance, the ACC has established the National Cardiovascular Data Registry. The ACC is also creating a website for patients in both English and Spanish that will explain diagnoses and talk about medications and their side effects. Despite great progress in addressing disparities, research has 41 

42 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS shown that bias is still a problem, as is lack of cultural competency and low health literacy. For example, in coronary artery disease there are disturbing disparities based on race and gender in terms of referrals and treatment. The following panel was designed to pro- vide us with input on ways to improve quality at the provider level by addressing health disparities and health literacy issues. Health plan level Grace H. Ting, M.H.A. WellPoint The convergence of quality improvement, reducing health disparities, and improving health literacy is the focus of a pilot program at WellPoint, a health plan covering 35 million members. The program gathers data for the purpose of developing profiles of patients with particular conditions, such as diabetes. Data can also help researchers identify factors that could be associated with patient behaviors, such as adherence to treatment protocols, said Grace Ting of WellPoint. Therefore, the first step of the program is collecting valid data, as discussed by previous speakers. Because collecting this type of data on individual members is often expensive and time consuming, WellPoint developed its Proxy Methodology to identify members of different racial and ethnic groups that may benefit from more focused quality improvement interventions. This methodology com- bines geocoding and name analysis to develop race and ethnicity estimates that can be rolled up to characterize health care quality improvement needs at a variety of levels, including the regional level, health plan level, and provider practice group level. WellPoint has also engaged physician groups in quality improvement initia- tives to address disparities. Questions have been raised about whether proxy data are good enough for analyses and application in quality programs. As can be seen from Table 4-1, indirect methods have a high degree of accuracy when comparing population groups. WellPoint has con- ducted extensive testing on the validity of proxy data by compar- ing internal self-reported data with data generated using the Proxy Methodology. WellPoint has also conducted some health disparities market research to develop a profile of “adherent” diabetic patients who take proactive care of their health. In the first phase of this three- phased approach, focus groups of adherent individuals were con- 

INTEGRATION AT THE PRACTITIONER LEVEL 43 TABLE 4-1  Aggregate Demographics—Predicted Versus Reported White/ Approach Hispanic Asian Black Other N = 192,096 (%) (%) (%) (%) Surname only 46.1 6.6 7.1 40.2 Geocoding only 41.3 7.9 11.9 39.0 WellPoint model 52.1 7.9 14.7 25.3 Member self- 52.0 8.0 14.8 25.2 reported data ducted to discover factors (e.g., behavioral, situational, psychologi- cal) that facilitate proactive action for health management on the part of members. One of the findings was that low health literacy can be an indicator of poor communication between patient and provider for such reasons as patients not being told how to care for their conditions or being afraid to ask questions. In phase two, based on the results of the focus groups, interven- tions and materials were developed and tested with focus groups of “nonadherent” individuals. The final phase developed pilot deploy- ment recommendations, including proposed metrics to measure the success of these enhancements. WellPoint’s pilot program is in the process of making systematic changes in three specific areas. First, disease management programs are being enhanced to be more culturally and linguistically specific, including recognizing patients’ spirituality, family, and community. Through the development of new materials to disseminate infor- mation, WellPoint hopes to address fears by producing improved, individually relevant targeted information. Second, benefit struc- tures are undergoing changes to reduce the financial burden of care. For example, to help diabetic patients with their prevention needs, WellPoint may cover glucometers or reduce patient copays for insulin. Third, clinical staff is to be better matched to patient populations, both culturally and linguistically. Significant training efforts in terms of culturally sensitive scripts and webpages for use by all staff (e.g., physicians, nurses, and administrative staff) are under way when treating specific populations such as the Latino and African American populations. Efforts will need to be made to explore the best ways to communicate with target audiences such as development of DVDs, videos, and media entertainment to promote 

44 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS lifestyle changes (e.g., better diet) and provide tips on living with health conditions. Ting concluded by saying that a fine line exists when promot- ing culturally and linguistically relevant materials. One could be perceived as stereotyping or racially profiling members. Therefore, transparency and honesty are critical in the development of such programs. Ambulatory care Level Thomas D. Sequist, M.D., M.P.H. Harvard Vanguard Outpatient providers can combine their intimate knowledge of patients and understanding of the health care system in unique ways to address disparities in care. Harvard Vanguard Medical Associates (HVMA) is an integrated delivery system with 14 health centers and approximately 130 primary care physicians who care for 300,000 adult patients, of whom 15,000 are diagnosed with diabetes. Begin- ning in the mid-1990s, HVMA began to implement a new model to improve the delivery of diabetes care. This first included implement- ing an electronic health record and creating point-of-care electronic decision support (“reminders”) for physicians. This was followed by developing a more robust electronic diabetes data registry that allowed tracking of all patients with diabetes and enabled identifica- tion and outreach to patients overdue for recommended care in the form of automated mailings. Recognizing that clinical decision support tools and patient mailings alone were insufficient to achieve good diabetes care, the next phase of improvement focused on restructuring chronic care delivery. This led to changes in the HVMA primary care system that identified new roles for all care team members, including nurse practitioners, nurses, and medical assistants, and additional training in such areas as health promotion and patient engagement. Diabe- tes dashboard reports, containing a list of each clinician’s patients with diabetes, were provided to each physician on a quarterly basis. These reports contained key clinical information including recent laboratory test results, blood pressure measurements, medications, and recent referrals. Such information was used by clinical care teams to develop treatment plans both between and during office visits. With these changes, the quality of diabetes care improved and the racial disparity in care processes (e.g., annual cholesterol testing) 

INTEGRATION AT THE PRACTITIONER LEVEL 45 were eliminated over time. Patients also realized better intermediate outcomes following these interventions, with more patients achiev- ing lower levels of cholesterol. However, a significant gap in rates of cholesterol control between white and black patients unfortunately persisted. One potential reason for this gap is a persistent difference in prescribing behaviors of physicians, with black patients remain- ing less likely than whites to be prescribed statins. It is important to note that the focus of these interventions within the HVMA primary care system was not to improve minor- ity care or to reduce disparities—it was to improve the quality of care for patients with chronic conditions, exemplifying the positive impact quality improvement interventions can have on disparities. However, such nontargeted interventions are not a perfect solution, as demonstrated by the persistent disparities described above. A critical byproduct of quality improvement interventions is their potential impact on racial disparities. Recognition of this has led to the question of what role ambulatory care can have on reduc- ing disparities. Outpatient physicians can play an active role in eliminating disparities by addressing patients’ individual health care needs and identifying barriers within the health care system to better guide patients toward improved health outcomes. A central advantage to the outpatient physicians’ roles is the direct involve- ment in clinical care and the trust developed through long-lasting patient–provider relationships. The trust engendered in patient– provider relationships can help improve patient experiences of care, which has implications for improved adherence and quality of care among minority patients. To move the field forward, Sequist recommended increased col- lection of race and ethnicity data, improving physician awareness of the importance of disparities within their local health care environ- ment, and developing targeted interventions to address disparities. In terms of data collection, 75 percent of medical groups currently do not collect race or ethnicity data. Among the 25 percent of groups collecting these data, the completeness and accuracy of the data are not clear. Echoing Ting’s point, 80 to 90 percent of patients are comfortable with the collection of race/ethnicity data, but health care providers must be honest and foster transparency about how the data will be used. Improving physician awareness is necessary to move the field forward because many physicians do not recognize the importance of disparities, particularly within their local health care environ-   Statins are medications to control cholesterol. 

46 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS ment, such as within their own panel of patients. This failure to recognize potential biases in health care delivery and ultimately disparities in health outcomes at the local level persists, despite the fact that disparities have been shown to be fairly evenly distributed throughout the entire system. A potentially useful strategy might be to make clinicians more aware of their performance through nonpublic performance reporting of racial disparities. Health care systems should explore training in cultural competency for clini- cians to raise awareness of disparities and ultimately improve com- munication with minority patients regarding the management of their chronic condition (e.g., choosing healthy foods, getting proper exercise, and controlling stress). Finally, the effect on disparities of increasingly popular policies to improve quality of care must be considered. In particular, pay for performance and public reporting may both have considerable unintended consequences, potentially worsening disparities. Poli- cies should be designed in ways that actually alleviate disparities, not augment them, Sequist concluded. Hospital Level Michael P. Pignone, M.D., M.P.H. University of North Carolina People with low health literacy skills are at risk for a number of adverse health outcomes (Dewalt et al., 2004a; Pignone et al., 2005). The relationship between literacy and adverse health outcomes, however, is complex. Some aspects of preventive care, for exam- ple, do not differ by literacy status, indicating that more research is needed to identify the mechanisms by which literacy leads to adverse health outcomes. As others have discussed, health care is only one of the factors that affect health. Patients with greater access to resources such as higher literacy, greater socioeconomic status, and health insurance coverage may find it easier to avoid poor health outcomes, despite good or bad quality of care. More vulnerable people with fewer resources are at greater risk of receiving poor care and having bad outcomes. Systems are currently suboptimally organized to deliver high quality of care, offering opportunities for improvement. Organized care can reduce literacy-related health disparities. Appropriate inter- ventions to change how health care is organized can make a differ- ence in health outcomes. 

INTEGRATION AT THE PRACTITIONER LEVEL 47 One example is an intervention to improve care for patients with congestive heart failure (CHF). CHF affects 5 million Americans and is the leading cause of hospitalizations among the elderly. Of those hospitalized, 25 to 50 percent are readmitted within 3 to 6 months. Half of CHF admissions are thought to be preventable with good medical care and good self-care. However, good self-care is not well taught. Currently, patients are often overloaded with information about how to live with CHF; guidelines exist for approximately 25 best practices (Grady et al., 2000). As a result, patients do not necessarily know how best to manage their health care. Pignone and colleague Darren DeWalt sought to improve teaching of CHF self-care. After reviewing the literature, reflecting on clinical experiences, and con- ferring with patients, they developed materials that boil down to seven guidelines based upon literature review and clinical experi- ence (DeWalt et al., 2004b). They found that providers often use a traditional biological model, but that patients need teaching in a different, more patient-centered manner. Thus, materials should be developed that do not overemphasize anatomy and pathophysiol- ogy at the expense of focusing on symptoms and impact on func- tional status (see Figure 4-1). Another example of their educational materials is a visual guide for controlling fluid balance. Many patients are never told what their optimal weight should be in terms of fluid balance. Patients often receive general verbal instructions that “if your weight goes up or down 3 pounds, either double or halve your medication.” This type of instruction is too abstract for many patients to follow. To help patients better understand directions, visual guides such as the one in Figure 4-2 were developed. These materials must be complemented with training so that patients can use the tools and manage their conditions on a daily basis. A randomized trial of these interventions was conducted with 130 patients. The incidence rate for hospitalizations and death decreased by almost 40 percent for those receiving the self-care pro- gram as compared to those who received a standard heart failure pamphlet alone (DeWalt et al., 2004b). The reduction in hospitaliza- tions was even greater for those with low literacy levels compared to those with adequate literacy. These examples suggest that interventions may differentially help groups of people with low levels of literacy and may reduce literacy-related disparities. If this notion is accepted, three actions must take place. First, the organizational structure of health care must be changed because most places are too decentralized and 

48 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS Figure 4-1.eps FIGURE 4-1  Example of easily understandable, patient-centered materials. bitmap lack a strong focus on clinical quality improvement, thereby limit- ing leadership and clinicians’ abilities to widely enforce quality improvement initiatives. Compounding this is the fact that most health care leaders lack experience in implementing quality improve- ment interventions. Second, the financing systems must change to compensate patients for nonphysician encounters. Third, political advocacy should be cultivated to organize low-literacy patients to garner attention to their needs. The infrastructure for implementing health care quality improve- ment exists primarily in inpatient settings. Hence, interventions are 

INTEGRATION AT THE PRACTITIONER LEVEL 49 FIGURE 4-2  Visual guides for medication use. Figure 4-2.eps bitmap less common in outpatient settings, which are generally better envi- ronments to train patients in self-care techniques. The health care system should be viewed as a full system working in both settings, as opposed to separate inpatient and outpatient systems, thus facili- tating a more systemic focus on care transitions. For the future, Pignone concluded, universal recognition of bar- riers to high-quality care is critical and requires the involvement of institutional leadership, which is currently lacking in many places. Support from institutional leaders would facilitate routine tracking of process and outcomes measures, as well as integration of system- based approaches. To support institutional commitment, purchasers and payers must work together to reorganize the reimbursement system. 

50 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS Reaction panel Nicole Lurie, M.D., M.S.P.H. RAND Corporation On the basis of experiences with the National Health Plan Disparities Collaborative, action must take place now. It is often understood that measurement is central to change, but while many providers have started addressing disparities and literacy, many others have not yet begun. Methods are available for collecting data in relatively quick and inexpensive ways—for example, using indirect measures such as what is done by WellPoint with its Proxy Methodology for identifying ethnicity. Similar methods for health literacy became available in the summer of 2008 from RAND and American Institutes for Research. These data collection efforts allow for collection of critically needed data that can be used to identify those people needing special attention. In environments with limited resources, simple tools may be used to identify populations in need. For example, mapping is a useful tool to identify disparities, gaps in literacy, and differences in quality measures and should be used to identify clusters of “hot- spots” where patients are not receiving appropriate care. In this way, interventions with translations into Spanish, for example, would be implemented only in geographic areas with high Spanish-speaking populations, as opposed to the entire country. Finally, Lurie reinforced the need for collaboration and shared responsibility. Given the high rates of comorbidities in the United States, diseases can no longer be approached in isolation from each other. Sets of interventions that support care, improve literacy, and address disparities after visits with providers need to be developed for homes, workplaces, and schools. Large numbers of uninsured people in a community negatively affect the entire community because expectations for the community fall, resulting in worse care. Efforts must be put in place to engage stakeholders to become part of the solution.   The National Health Plan Disparities Collaborative consists of 11 health plans, both national and regional, from around the country. 

INTEGRATION AT THE PRACTITIONER LEVEL 51 Marshall Chin, M.D., M.P.H., F.A.C.P. University of Chicago Marshall Chin of the University of Chicago and a member of the Forum on the Science of Health Care Quality Improvement and Implementation responded to the panel by making six points based on his experiences with community health care and the Robert Wood Johnson Foundation’s Finding Answers program. First, he noted that all three panel members said cultural com- petency training for health care providers can help improve knowl- edge and skills, but this alone is not enough to change outcomes. Despite the fact that multifactorial interventions tend to be effective, health care providers are not taught in this way. Quality improve- ment and systems thinking are concepts often missing from health professional curricula. Even when present, this training is divorced from cultural competency and literacy training in schools. Second, culturally tailored quality improvement interven- tions are more effective than general quality improvement inter- ventions, as noted by Ting and Sequist. This conclusion was also found in the Finding Answers program, where being respectful of patients’ health beliefs and behaviors—even having cultur- ally appropriate artwork—led to the building of trust between patients and providers, critical in efforts to reduce disparities. Third, the importance of context, a concept central to the Forum on the Science of Health Care Quality Improvement and Implemen- tation’s discussions, must also be addressed. Quality improvement interventions to reduce disparities should be individualized to spe- cific contexts, such as different populations, settings, and financial situations. Few articles in the current literature describe interven- tions to bridge disparities in different contexts, identifying an area where more research is needed. Fourth, health care systems must understand the need for con- sumer engagement and become more involved at the community level. The rise of consumer engagement has two levels: Level one involves the decisions made by purchasers, employers, and large coalitions, while level two concerns individual communities and patients, and the work of people who bridge to the health care system such as community health workers. These are critical com-   Finding Answers: Disparities Research for Change is a Robert Wood Johnson Foundation program that “seeks to improve the quality of health care provided to patients from racial and ethnic backgrounds likely to experience disparities” (RWJF, 2008). 

52 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS ponents because they address the continuum of factors impacting health outcomes. Fifth, chronic care management requires new models of reim- bursement. Given the rise of chronic care, the reduced number of generalists, and the growing evidence of the need for primary care, the patient-centered medical home is a striking concept. The medi- cal home may soon be used to address reimbursement issues, such as payment for care coordination, and must be considered from the perspectives of both society and providers. Finally, pay-for-performance programs, as discussed by Sequist, should be specifically designed to reduce racial and ethnic dispari- ties. In the general literature, few articles focus on the effect of pay- for-performance programs on health disparities, stemming from the fact that only a small number of pay-for-performance programs are being designed with that focus. Chin concluded that while all six points reflect critical issues, none can be addressed independently because they highlight where bridges to different areas need to be made. For example, reforming training of health care providers to include quality improvement and systems builds a bridge to the field of professional education. These bridges must be built to strengthen the health care system and achieve the goal of integrating health literacy, disparities reduction, and quality improvement. Steve Somers, Ph.D. Center for Health Care Strategies Medicaid is a leverage point for change with 55 million benefi- ciaries and a budget of $360 billion. In this Medicaid population, 55 percent of the nonelderly are members of racially and ethnically diverse groups, thereby presenting a great opportunity to reduce disparities. It would be interesting to obtain data on health literacy levels within the Medicaid population. To improve quality and reduce costs, stakeholders must be con- vinced that these issues are important, which requires making a business case for quality. To make that business case, it is necessary to identify and stratify the populations (both beneficiaries and orga- nizations) for whom the greatest benefit can be obtained. Interven- tions should then be targeted at specific groups; one large group is Medicaid beneficiaries. Opportunities for improvement are particularly significant in the Medicaid population, where 65 percent of beneficiaries are in managed care plans and large numbers live with chronic illnesses and comorbidities. Data on Medicaid beneficiaries are measured by 

INTEGRATION AT THE PRACTITIONER LEVEL 53 individual states and are of variable quality. The Center for Health Care Strategies (CHCS) is working with some states to identify primary care practice sites that serve racially and ethnically diverse beneficiaries. For example, in Detroit, Michigan, 50 percent of Med- icaid beneficiaries are treated by practices run by only one or two doctors; 70 percent of Medicaid beneficiaries in Arkansas are treated by solo practitioners. Data should be gathered on these populations and be used to improve their care, with the goal of better health. Somers concluded with the hope that CHCS’s programs in states with high concentrations of diverse populations and often poor quality scores could stimulate cross-stakeholder and cross-payer col- laborations (i.e., state and health plans work together with providers to improve quality, reduce disparities, and address health literacy). Discussion Resource Management Decisions on the most effective use of resources must be made using both a systems approach (allocation of resources based on likelihood of doing the most good) and a universal precautions approach (provision of resources to all potential users); it is not an either/or situation, Lurie said. Some situations will involve univer- sal precautions, and others will require specific targeting. Even with universal precautions, available resources are often not enough, as people and groups tend to need more resources than they receive. The financial imperative and the bottom line cannot be ignored, Lurie said. Somers noted in agreement that often the business case for quality must be the starting point, beginning with high-need, high-cost populations. A spillover benefit will accrue to those orga- nizations and populations for which the business case is less strong because the degrees of improvement are fewer. Many health literacy interventions—for example, in the treatment of heart disease—have produced cost savings and benefits to both low-literacy patients and high-literacy patients, but to varying degrees. A balance must be found between the seemingly contradictory concepts of a one-size-fits-all approach to the general population based on evidence-based standards and individualization of care to specific needs and circumstances, Chin said. Business Case A question was asked about the necessity of having a return on investment for health care interventions, as some improvements 

54 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS might not be accompanied by a positive return on investment. Somers stated that it is necessary to start moving in this area and that the business case for quality is not solely measured in monetary terms; issues such as reputation and quality of life are also critical. Making the financial case for at least some situations is necessary, however. Lewin noted that the business case for structural improve- ment must be made (e.g., data collection, registries, information technology), stating that these improvements provide the basis for further improvements (e.g., public reporting). Capacity Building One questioner noted that the capacity to improve health lit- eracy at the societal level needs to be built, but asked how care should be delivered for “resourced” populations. Most efforts focus on under-resourced populations and therefore do not approach the issue from a population level. Lurie responded that every encounter and experience ought to be an opportunity to build health literacy, recognizing that many providers currently do not believe that build- ing health literacy is part of their responsibilities. The burden of developing health literacy, however, should not be placed solely on providers but also on the public health system, driven by the gov- ernment in a reinforcing relationship. The adult education community provides critical examples for building literacy skills, Pignone said. Medical Home In response to a question of whether the concept of medical homes should begin with physicians or potentially be viewed with a focus on nurses, community health workers, or patient navigators, Chin responded that many benefits exist to having a comprehensive, multidisciplinary team focus. The effectiveness of nurse-led systems and team interventions is a common theme found in disparities intervention literature.