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 improvement must be made (e.g., data collection, registries, information technology), stating that these improvements provide the basis for further improvements (e.g., public reporting).

One questioner noted that the capacity to improve health literacy 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 building 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 government in a reinforcing relationship.

The adult education community provides critical examples for building literacy skills, Pignone said.

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.